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Cardiac Event Detection

Reimbursement Policy:
Cardiac Event Detection

Effective Date:
February 25, 2019

Purpose:
Provides guidelines for cardiac event detection 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, it would not be necessary to perform a mobile cardiovascular telemetry (MCT) procedure or external patient activated single or multiple event recording with pre-symptom memory loop test more frequently than once in six months. Therefore, additional billings in excess of once every six months shall not be reimbursed.

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

Cardiovascular Monitoring Service codes included in this policy:

  • 93228
  • 93229
  • 93268
  • 93270
  • 93271
  • 93272

The CPT® codes 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 93228-93229 (External mobile cardiovascular telemetry [MCT]), or 93268-93272 (External patient activated ECG event recording) when billed more than once in a six month period by any provider.

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

In denied instances where the provider is participating, no member liability shall apply.

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 115_v1.0_11152017