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Local Coverage Determination (LCD)

Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring)

L34636

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34636
Original ICD-9 LCD ID
Not Applicable
LCD Title
Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring)
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 10/01/2023
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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Issue

Issue Description

Review completed with no change in coverage.
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Italicized font represents CMS national language/wording copied directly from CMS Manuals or CMS transmittals. Contractors are prohibited from changing national language.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment of those services that are considered to be medically reasonable and necessary.

Title XVIII of the Social Security Act section 1862 (a) (1) (D). This section states that no Medicare payment may be made under part A or part B for any expenses incurred for items or services that are investigational or experimental.

Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.

42 CFR, Section 410.32 Diagnosis x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. (a) Ordering diagnostic tests. All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses ther results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.

42 CFR, Section 411.15(k)(1) states any services that are not reasonable and necessary are excluded from coverage.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Long-Term ECG Monitoring is defined as a diagnostic procedure, which can provide continuous recording capabilities of ECG activities of the patient's heart while the patient is engaged in daily activities. These can include continuous, patient-demand or auto-detection devices. The purpose of these tests is to provide information about rhythm disturbances and waveform abnormalities and to note the frequency of their occurrence.

Cardiac Event Detection (CED) is a 30-day service for the purpose of documentation and diagnosis of paroxysmal or suspected arrhythmias.

Holter Monitoring (24-hour ECG monitoring) is a study used to evaluate the patient's ambient heart rhythm during a full day's (24 Hours) cycle. It is a wearable EKG monitor that records the overall rhythm and significant arrhythmias.

  1. Medical Necessity:

    The medical necessity indications listed in this policy must be present in order for these tests to be covered.
  2. Indications for external 48-hour ECG recording include one or more of the following:
    1. Symptoms:
      1. Arrhythmias
      2. Chest pain
      3. Syncope (lightheadedness) or near syncope
      4. Vertigo (dizziness)
      5. Palpitations
      6. Transient ischemic episodes
      7. Dyspnea (shortness of breath)
    2. Evaluation of the response to antiarrhythmic drug therapy.
    3. Evaluation of myocardial infarction (MI) survivors with an ejection fraction of 40% or less.
    4. Assessment of patients with coronary artery disease with active symptoms, to correlate chest pain with ST-segment changes.
    5. Other acute and subacute forms of ischemic heart disease.
    6. To detect arrhythmias post ablation procedures.
  3. The use of external electrocardiographic recording for greater than 48 hours and up to 7 days or for greater than 7 days up to 15 days by continuous rhythm recording and storage, may be considered medically necessary in patients treated for reasons listed in the diagnosis list to monitor for asymptomatic episodes in order to evaluate treatment response. The use of external electrocardiographic event monitors for greater than 48 hours and up to 7 days or for greater than 7 days up to 15 days that are either patient-activated or auto-activated may be considered medically necessary as a diagnostic alternative to Holter monitoring in patients who experience infrequent symptoms (less frequently than every 48 hours) suggestive of cardiac arrhythmias (i.e., palpitations, dizziness, presyncope, or syncope). (Refer to current CPT codebook)
  4. Long term 30-day monitoring: Telephonic Transmission of ECG involves 24 hour attended monitoring per 30-day period of time; no other EKG monitoring codes can be billed simultaneously with these codes.
    Indications for performing a Telephonic Transmission:
    1. Arrhythmias
    2. Chest pain
    3. Syncope (lightheadedness) or near syncope
    4. Vertigo (dizziness)
    5. Palpitations
    6. Transient ischemic episodes
    7. Dyspnea (shortness of breath)
    8. To initiate, revise or discontinue arrhythmia drug therapy.
    9. Evaluation of myocardial infarction (MI) survivors.
    10. Evaluation of acute and subacute forms of ischemic heart disease.
    11. Assessment of patients with coronary artery disease with active symptoms, to correlate chest pain with ST-segment changes.
Summary of Evidence

N/A
Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

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N/A

Revenue Codes

Code Description

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N/A

CPT/HCPCS Codes

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N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements
Medicare monitors for medical necessity, which can include frequency. Documentation would include a history and physical exam. The record should document the evaluation, which focuses on the cause(s) of the presenting symptoms and/or the need for this testing. Some examples are:

  1. The patient record has an evaluation and management service that documents the symptoms experienced by the patient.
  2. The patient has had a full workup in the past month with initial tests performed, and presents with continuing symptoms that indicate the need for up to 48-hour monitoring or long-term monitoring.
  3. The patient requires a change in antiarrhythmic medication. In this case, an assessment of the patient's complaints, the name of the medication stopped, and the name of the new medication should be indicated.
  4. In the case of referred tests, documentation of medical necessity may be requested from the referring physician. These are considered purchased diagnostic tests.
  5. Independent diagnostic testing facilities (IDTF) and suppliers must retain records that include:
    1. The referring physician's written orders; and
    2. The identity of the employee setting up the tracing.

Documentation should be submitted as indicated when requested or when unusual circumstances are present.
Sources of Information
N/A
Bibliography
  1. ARROCHA A, KLEIN GJ, BENDITT DG, SUTTON R, KRAHN AD. Remote electrocardiographic monitoring with a wireless implantable loop recorder: Minimizing the Data Review Burden. Pacing and Clinical Electrophysiology. 2010;33(11):1347-1352. doi:10.1111/j.1540-8159.2010.02857.x
  2. Kristiansen J, Korshøj M, Skotte JH, et al. Comparison of two systems for long-term heart rate variability monitoring in free-living conditions - a pilot study. BioMedical Engineering OnLine. 2011;10(1):27. doi:10.1186/1475-925x-10-27
  3. Zimetbaum P, Goldman A. Ambulatory arrhythmia monitoring. Circulation. 2010;122(16):1629-1636. doi:10.1161/circulationaha.109.925610

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/01/2023 R16

Posted 09/28/2023 Review completed 0/24/2023 with no change in coverage. Bibliography updated to correct AMA format.
  • Other
10/28/2021 R15

10/28/2021 Review completed 09/27/2021. Sources of Information moved under Bibliography and updated to AMA format.
  • Other (Code updates)
01/01/2021 R14

CPT/HCPCS Annual Code Update. Under Coverage Indications, Indications, and/or Medical Necessity section C the language was changed to reflect code updates to say from 7 days up to 21 days to say greater than 48 hours and up to 7 days or for greater than 7 days up to 15 days.
  • Other (Code updates)
11/01/2019 R13

The following CPT/HCPCS codes were removed from section C to comply with CR10901 :0295T, 0296T, 0297T and 0298T.
  • Other (Compliance with CR 10901)
10/31/2019 R12

10/31/2019 Change Request 10901 Local Coverage Determinations (LCDs): it will no longer be appropriate to include Current Procedure Terminology (CPT)/Health Care Procedure Coding System (HCPCS) codes or International Classification of Diseases Tenth Revision-Clinical Modification (ICD-10-CM) codes in the LCDs. All CPT/HCPCS, ICD-10 codes, and Billing and Coding Guidelines have been removed from this LCD and placed in Billing and Coding: Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) article linked to this LCD.
  • Other (Compliance with CR 10901)
10/01/2019 R11

09/26/2019 ICD 10 code update: the following are added to Group 1: I48.11, I48.19, I48.20, I48.21 and I48.1, I48.2 are deleted. Review completed 08/13/2019.
  • Revisions Due To CPT/HCPCS Code Changes
12/01/2018 R10

12/01/2018 Added codes G45.0, G45.1, G45.2, G45.3, G45.4, and G45.8 to Groups 1, 2 and 3.
  • Revisions Due To CPT/HCPCS Code Changes
03/01/2018 R9

03/01/2018 Annual review done 02/02/2018. Punctuation corrections made. No change in coverage.
  • Other (Annual review)
10/01/2017 R8

 

10/01/2017 Per ICD-10 Code updates: to Groups 1, 2, and 3 added diagnosis codes: I21.9, I21.A1, I21.A9 and R06.03. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 
  • Revisions Due To ICD-10-CM Code Changes
06/01/2017 R7 06/01/2017 Added diagnosis code G45.9 to Group 1 Memory Loop recordings (codes 93268, 93270, 93271 and 93272), to Group 2 Other up to 48-hour recordings (codes 93224, 93225, 93226, 93227, 93228, and 93229) and to Group 3 More than 48 hours up to 21 day recordings (codes 0295T, 0296T, 0297T and 0298T).
  • Revisions Due To ICD-10-CM Code Changes
03/01/2017 R6 03/01/2017 Annual review done 02/02/2017. For clarification, added the following paragraphs: Group 1 Paragraph: Memory Loop recordings (codes 93268, 93270, 93271 and 93272); added Group 2 Paragraph: Other up to 48-hour recordings (codes 93224, 93225, 93226, 93227, 93228, and 93229); and added Group 3 Paragraph: More than 48 hours up to 21 day recordings (codes 0295T, 0296T, 0297T and 0298T).
  • Other (Annual review)
04/01/2016 R5 04/01/2016: Annual review done 02/30/2016. Updated Sources of Information; corrected typos.
  • Other (Maintenance-annual review)
01/01/2016 R4 01/01/2016: 2016 HCPCS updates: 0295T long description change. Effective 10/01/2015 added R07.9 to Group 1, 2 and 3 ICD 10 Group Paragraphs.

  • Other (ICD 10 additions)
10/01/2015 R3 12/01/2015: CAC information removed per CMS guidance. Added I48.91 and I48.92 to Group 1 Paragraph ICD 10 codes; effective 10/01/2015. Added CMS statement regarding italicized font and removed unnecessary CMS sources. Corrected typos. Added Group 2 and Group 3 ICD 10 codes identical to Group 1 ICD 10 codes for clarity-all three groups have the same ICD 10 indications.

  • Other (ICD-10 additions)
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R2 10/06/2015 - Due to CMS guidance, we have removed the Jurisdiction 8 Notice and corresponding table from the CMS National Coverage Policy section. No other changes to policy or coverage.
  • Other
10/01/2015 R1 04/01/2015: Annual review completed 02/13/2015, references updated, format changes made, no change in coverage.
  • Other (Maintenance, annual review)
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Associated Documents

Attachments
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Related National Coverage Documents
NCDs
20.15 - Electrocardiographic Services
Public Versions
Updated On Effective Dates Status
09/19/2023 10/01/2023 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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