Ambulatory Electrocardiographic Monitoring

Reimbursement Policy:
Ambulatory Electrocardiographic Monitoring

Effective Date:
February 25, 2019

Purpose:
Provide guidelines for ambulatory Electrocardiographic Monitoring services when appropriately billed by professional providers.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • ITS Home In-Network
  • FEP
  • SHBP non MA

All Insured Individual, Commercial medical plans, and Medicare Advantage Plans, are included.

ASO accounts will be included as an Opt-In option for additional claims editing on an account-by-account basis

Policy:
According to CMS policy, external electrocardiographic monitoring (e.g. Holter monitor) (93224-93227, 0295T-0298T) should occur at the most twice every six months. Therefore, 93224-93227, or 0295T-0298T shall not be reimbursed if billed more frequently than two times within six months.

Performance of this service at greater frequencies is not typically required in virtually all clinical circumstances, and this policy conforms with industry norms.

The CPT® codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Horizon BCBSNJ shall deny 93224-93227 or 0295T-0298T (Ambulatory [ECG]) when billed more than twice in a six month period.

Horizon BCBSNJ shall reimburse 93224-93227 or 0295T-0298T (Ambulatory [ECG]) when it is NOT billed more than twice in a six month period.

No additional reimbursement will be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In denied instances where the provider is participating, member liability shall not be applied.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

History:
11/15/2017: Policy approved

CPT® is a registered trademark of the American Medical Association.

Policy 114_v1.0_11152017