Local Coverage Determination (LCD)

Real-Time, Outpatient Cardiac Telemetry

L34997

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Contractor Information

LCD Information

Document Information

LCD ID
L34997
LCD Title
Real-Time, Outpatient Cardiac Telemetry
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 10/17/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
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CMS National Coverage Policy

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for real-time, outpatient cardiac telemetry services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify, or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for real-time, outpatient cardiac telemetry services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:


IOM Citations:

  • CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80, Coverage of diagnostic x-ray, diagnostic laboratory and other diagnostic tests
  • CMS IOM Publication 100-03, National Coverage Determinations (NCDs) Manual, Part 1, Section 20.15, Coverage for electrocardiographic services under Medicare Part B


Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
  • Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
  • Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.


Federal Register References:

  • 42 CFR, Section 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Real-time, outpatient cardiac telemetry involves the use of an automatically activated system that requires no patient intervention to either capture or transmit a dysrhythmia when it occurs. The purpose of this service is for real-time, continuous, long term (> 24 hours) cardiac surveillance of patients in order to identify and document a suspected and/or paroxysmal dysrhythmia. The term "real-time” in this Local Coverage Determination (LCD) is defined as the immediate transmission of the patient’s cardiac activity to a receiving center (as defined below) which converts this electronic transmission into a visible image that is constantly and continuously displayed on a monitor in the receiving center so that qualified personnel (as defined below) located in the receiving center can provide immediate and accurate surveillance of the patient’s cardiac activity. The device utilizes technology that allows for the electronic transmission of the electrocardiogram (ECG) waveform in real time to the receiving center. A receiving center is a facility, such as a physician’s office, Independent Diagnostic Testing Facility (IDTF) or other specified station that is equipped and staffed with qualified personnel to assess electrocardiographic data and to initiate appropriate management action. The patient's physician is made aware of dysrhythmias by qualified personnel based on pre-determined notification criteria, tailored to the patient by the physician.

In this system, the patient wears a telemetry transmitter that sends the ECG to a computer with modem where the real-time analysis occurs. Qualified personnel constantly provide ECG surveillance while in attendance at the receiving center. All transfer of ongoing telemetry surveillance services to other qualified personnel, including those who may be located at a different receiving center, occur seamlessly, with no gaps in patient surveillance. Qualified personnel at receiving centers thus provide patient telemetry surveillance 24 hours a day, seven days a week. The patient's physician is notified of ECG abnormalities based on the notification criteria. This dysrhythmia recognition and physician notification must allow for immediate medical intervention. An answering service/answering machine does not fulfill this requirement. In addition, this system provides an analysis and report of 24 hours of monitoring, similar to Holter studies. Therefore, the concomitant use of real-time cardiac telemetry, Holter monitoring, and/or event monitoring would be considered not medically necessary.

Covered Indications

Medicare coverage for this service is limited to patients who have demonstrated a specific need for this type of cardiac telemetry service. The ordering physician must have determined and documented that patients who require this service are at low risk for a life-threatening cardiac event. In addition, the medical record must clearly demonstrate that the results of this testing will provide diagnostic and/or treatment information useful in the ongoing management of the patient.

The following uses of real-time, outpatient cardiac telemetry are considered medically reasonable and necessary:

  1. Detection, characterization and documentation of symptomatic transient or paroxysmal dysrhythmia when the frequency of the symptoms is limited and the use of a 24-hour ambulatory ECG is documented in the medical record to be unlikely to capture and record the dysrhythmia, or
  2. Other testing and/or monitoring/recording/telemetry has been unrevealing. The ordering physician must document the prior testing performed and the results. This information must be maintained in the patient’s medical record and be available upon request, or
  3. Prolonged monitoring is required specifically to ensure the absence of atrial fibrillation prior to the discontinuation of anticoagulation therapy.

Coverage Limitations

Real-time outpatient cardiac telemetry is considered medically unnecessary if it is unlikely to provide clinical data or information beyond that which has already been obtained from a previous test or if other testing (e.g., ECG, 24 hour Holter, etc.) could be expected to provide the data/information needed for the diagnosis and/or treatment of the patient’s condition/symptoms.

The receiving station must be staffed with qualified personnel who provide real-time surveillance while located at the receiving station. The qualified personnel must be able to read ECGs and rhythm recordings and be capable of directing the patient if it is determined by the qualified personnel that emergency care is required. Any transfer of ongoing surveillance services to other qualified personnel, including qualified personnel at another receiving station, must occur in a seamless manner with no gaps in patient surveillance. Surveillance must occur continuously, 24 hours a day, 7 days a week while the patient is wearing the device.

A test not ordered by a physician or qualified non-physician practitioner treating the beneficiary will be denied as non-covered.

Real-time outpatient telemetry should not be used primarily for the daily transmission of ECG rhythm strips or telemetry recordings, in the absence of identified symptoms necessitating diagnosis/treatment, as stated in this LCD.

Outpatient cardiac telemetry should only be reported for patients being evaluated with cardiac telemetry as outpatients and is considered not medically necessary if used for review and interpretation of ECG rhythm strips generated by inpatient cardiac monitors or telemetry. It should not be reported for patients in hospitals, emergency rooms, skilled nursing facilities or other specialized facilities and, if reported as such, will be denied.

Real-time cardiac telemetry is considered to be a service that lasts up to 30 days and is performed for the purpose of documenting and diagnosing paroxysmal or suspected dysrhythmias. The performance of this test is based upon the ordering physician’s determination that the patient’s pre-test incidence of symptoms is believed to be related to a dysrhythmia. This service is considered not medically necessary for patients who do not have, or are not suspected of having, clinically significant recurrent dysrhythmias.

Testing for more than 30 consecutive days is only rarely medically necessary and the need for the continued testing must be documented by the treating physician. The inability to document a dysrhythmia during a 30-day test period is not sufficient justification to perform a second or subsequent test. It is unlikely to be medically necessary to repeat a second test within a year of a prior test.

Real-time cardiac telemetry is not covered for outpatient monitoring of recently discharged post-infarct patients and will be denied as not medically necessary.

Each patient is required to have a recorder for his/her own exclusive use throughout the duration of the monitoring period. Recorders may not be “shared” among two or more patients, regardless of the environment or site of the service. Services will be denied as not medically necessary when patients do not have exclusive use of a recorder for the entire service period (up to 30 days).

Internal controls of entities performing this test must ensure uninterrupted 24/7 surveillance. Any and all transfer of patient cardiac surveillance from qualified personnel to other qualified personnel, including those who may be located at another receiving center, must occur in a seamless manner with no gaps in the provision of the surveillance service. Surveillance by qualified personnel must be performed within facilities located within the United State and its Territories. Services ordered by and/or performed by providers that are located outside of the United States or its Territories will be denied as non-covered.

Providers may not report the hook-up of outpatient cardiac telemetry as this is included in the reimbursement of the technical portion of the service.

Real-time, outpatient cardiac telemetry is contraindicated in patients considered by their physician to be at high risk of developing sustained ventricular tachycardia or ventricular fibrillation. Such patients may be more appropriately cared for in a hospital setting.

Real-time cardiac telemetry is not indicated for all patients with known or suspected dysrhythmias. It is considered reasonable and necessary only in circumstances where traditional Holter monitoring and/or other cardiac event recording is not expected to provide adequate information or has been unsuccessful in the diagnosis and/or treatment of the patient.

This service is considered to be not reasonable and necessary for all patients with symptoms such as palpitations, dizziness, or weakness. To be considered medically necessary, the ordering physician must document that he/she has concluded that the patient’s symptoms are severe enough to warrant further investigation, an underlying dysrhythmia is a likely cause of their symptoms, and that the identification of the suspected dysrhythmia can only be determined through the use of this service. This information must be clearly documented in the patient’s medical record.

Real-time cardiac telemetry is not covered when used for screening.

The use of multiple forms of cardiac surveillance services (e.g., Holter monitor, other event recorder) provided to the same patient on the same day is NOT medically necessary.

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.


Provider Qualifications

The cardiac problems experienced by patients receiving this service, and the potential sequelae or complications of these problems, may be emergent and complex. In order to ensure quality of care to the Medicare beneficiaries receiving this service, this service should be ordered and interpreted by providers who, based upon their training and clinical experience, maintain the skills necessary for the appropriate management of these patients. These providers should also possess a thorough knowledge of the patient receiving the service. As always, concerns or issues identified by this contractor will be referred to the appropriate Medicare Quality Improvement Organization.

The procedure must be performed under the general supervision of a physician specializing in cardiology or internal medicine. Refer to CMS Publication IOM 100-02, Medicare Benefit Policy Manual, Chapter 15 Section 80 for complete information regarding general supervision.

Qualified personnel providing surveillance in receiving centers must possess the knowledge and skill necessary to accurately interpret ECGs and cardiac rhythms, and must be able to provide patient direction in emergency situations. Examples of qualified personnel may include RNs, EMTs, or individuals with Certified Cardiographic Technician (CCT) or Certified Rhythm Analysis Technician (CRAT) certification.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information


Refer to the Local Coverage Article: Billing and Coding: Real-Time,Outpatient Cardiac Telemetry, A52995 for all coding information.


Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The medical record documentation must support the medical necessity of the services as stated in this policy.
  4. Documentation supporting the medical necessity of the telemetry, as detailed in the Indications and Limitations of Coverage and/or Medical Necessity section must be maintained by the ordering physician and be available to the contractor upon request. In cases where the medical record is illegible, such that reasonable and necessary criteria cannot be determined, the claim will be denied as not medically necessary.
  5. The following documentation supports the technical component of the service and must be maintained by the surveillance center and be available to the contractor upon request:
    • The order for the service
    • Appropriate patient selection criteria as outlined in the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy
    • Copies of transmitted ECG and response by the surveillance center
    • Reports to the ordering physician
    • Physician contacts and related reports
    • Summary report at the end of the monitoring episode
    • Documentation of level of training and certification for qualified personnel
    • Documentation of plan for quality control for ECG surveillance
    • Documentation of procedures for emergency management of patients
    • Documentation of plan to ensure uninterrupted 24/7 surveillance of patients
  6. The medical record must document those times when the physician was contacted by the surveillance center as a result of the detection of dysrhythmias according to the pre-determined criteria, tailored to the patient by the physician. In addition, the medical record must contain the action that was taken by the physician as a result of this notification. This documentation includes those situations when the physician determines that no action was necessary.

Additional Information
N/A

Appendices
N/A

Utilization Guidelines

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

This telemetry service is not expected to be reported more than once in a 30-day period. Claims reporting more than one real-time telemetry service in a 30-day period are subject to denial.

This telemetry service is expected to not be reported more than once in a twelve-month period in the absence of new or recurrent undiagnosed symptoms. Claims reporting more than one monitoring episode in a twelve-month period are subject to denial.

Sources of Information


Contractor is not responsible for the continued viability of websites listed.

Other Contractors’ Policies

Contractor Medical Directors

Original JH ICD-9 Source LCD L33075, Real-Time, Outpatient Cardiac Telemetry

Original JL ICD-9 Source LCD L27520, Real-Time, Outpatient Cardiac Telemetry

Bibliography
  1. Consultants in cardiology
  2. Cardiac Telecom Corporation information
  3. CardioNet, Incorporated information
  4. FDA approval of CardioNet Ambulatory ECG Monitor with Arrhythmia Detection
  5. FDA approval of HeartLink II (Arrhythmia Detector and Alarm System)
  6. Joshi AK, Kowey PR, Prystowsky EN, et al. 'First Experience with a Mobile Cardiac Outpatient Telemetry (MCOT) System for the diagnosis and Management of Cardiac Arrhythmia.' American Journal of Cardiology, 2005;95(7).
  7. Kadish AH, Reiffel JA, Clauser J, et al. “Frequency of Serious Arrhythmias Detected With Ambulatory Cardiac Telemetry”. American Journal of Cardiology 2010; 105:1313-1316
  8. Kowey PR, et al. ‘First Experience with a Mobile Cardiac Outpatient Telemetry (MCOT) System for the Diagnosis and Management of Cardiac Arrhythmia.’ NASPE Heart Rhythm Society 24th Annual Scientific Sessions. May 2003.
  9. Olson JA, Fouts AM, Padanilam BJ, et al. "Utility of Mobile Cardiac Outpatient Telemetry for the Diagnosis of Palpitations, Presyncope, Syncope, and the Assessment of Therapy Efficacy." Journal of Cardiovascular Electrophysiology, Accessed Online March 2007.
  10. Prystowsky EN. "Assessment of Rhythm and Rate Control in Patients with Atrial Fibrillation." Journal of Cardiovascular Electrophysiology, 2006; 17(9)(supp).
  11. Rothman SA, Laughlin JC, Seltzer J, et al. "The Diagnosis of Cardiac Arrhythmias: A Prospective Multi-Center Randomized Study Comparing Mobile Cardiac Outpatient Telemetry Versus Standard Loop Event Monitoring." Journal of Cardiovascular Electrophysiology, 2007;18(3).
  12. Saarel EV, Sierba R. The Cleveland Clinic Foundation, Cleveland OH; 'Initial Experience with a Novel Cardiac Outpatient Telemetry System for Pediatric Patients with Suspected Arrhythmia.' Heart Rhythm 2005 Scientific Sessions.
  13. Tarakji KG, Natale A, Wazni O, et al. Cleveland Clinic Foundation, Cleveland OH; 'Incidence of Asymptomatic Atrial Fibrillation Recurrence Post Pulmonary Vein Isolation Using a Novel Continuous Event Monitoring System'. Heart Rhythm 2005 Scientific Sessions.
  14. Vasamreddy CR, Dalal D, Jayan V, et al. Johns Hopkins School of Medicine, Baltimore MD; 'Symptomatic and Asymptomatic Atrial Fibrillation in Patients Undergoing Radiofrequency Catheter Ablation.' ACC Annual Scientific Sessions 2005.

Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
10/17/2019 R3

LCD revised and published on 10/17/2019. Consistent with CMS Change Request 10901, all billing and coding information including the entire coding section has been removed from the LCD and placed into the related Billing and Coding Article, A52995. All CPT codes and coding information within the text of the LCD has been placed in the Billing and Coding Article. Information related to provider qualifications has been moved from the Utilization Guidelines to the new section of the policy titled Provider Qualifications and language that is contained in the CMS manuals has been deleted and replaced with the appropriate reference. The sources have been moved to the bibliography section and numbered.

  • Other (CMS Change Request 10901)
10/01/2015 R2 LCD revised to add diagnosis code Z79.01 to group 1 with asterisk notation.
  • Other (Addition of diagnosis code that was inadvertently left off of LCD in transition to ICD-10.)
10/01/2015 R1 LCD revised to remove incorrect manual citation.
  • Other (Removed incorrect citation.)

Associated Documents

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