Tips for Coding for WCD Patient Follow-Up and Management, Including Updates for 2020

The American Medical Association and Medicare introduced codes and coverage for remote monitoring of physiologic data with external devices in January 2019. Many organizations are providing remote monitoring with these devices but not reporting the new service codes. This article presents an explanation of the newly covered services and summarizes the applicable documentation and coding rules.

Introduction

Wearable cardioverter defibrillators (WCDs) are worn by patients identified to be at risk for sudden cardiac arrest, providing protection during their changing condition while permanent risk has not yet been established. WCDs have a class II recommendation for a range of patient types, including both ischemic and non-ischemic causes of left ventricular dysfunction (ejection fraction ≤35%). In addition to the detection and treatment of ventricular tachyarrhythmias, WCDs also capture data that can be used to assess a patient’s clinical progress over time.

These features provide the physician and practice with a platform to manage patients during the early period following a cardiac event, including the ability for early intervention when evidence of a decline in the patient’s status exists.

Medicare provides coverage for in-person WCD interrogations as well as remote monitoring of physiologic data captured by external devices, which includes WCDs (as of January 1, 2019).

Patient Management with WCDs

The WCD captures a spectrum of patient data, as outlined below.

• The WCD continuously monitors the patient’s ECG signal and heart rate, thereby capturing episodes of non-sustained and sustained ventricular tachyarrhythmias, some types of atrial fibrillation, severe bradycardias, and changes to resting and nocturnal heart rates. The patient can also interact with the device to manually record short segments of ECG data, for example, in the presence of symptoms.
• The WCD also captures patient activity level (step count), body position and angle, and can direct the patient to perform a six-minute walk test or answer health survey questions.
• An online patient data management system provides the prescribing clinician (MD, NP, PA) and their clinical staff (RNs and MAs) with the ability to review the patient data downloaded from the WCD. Data contained within the online system can be accessed via regular logins, or by alerts that can be customized by the user (eg, text, phone, email).
• The patient data captured by the WCD can be used in a variety of ways to enhance patient management. For example, clinicians can view trends in data over time following a hospital discharge, or they may be alerted if a specific parameter of interest has changed and requires intervention.

Coding & Billing for Physiologic Monitoring with WCDs

Remote Services:

Changes to CPT codes in the American Medical Association’s 2019 CPT Book include the introduction of three codes specific to remote physiologic monitoring: 99453, 99454, and 99457. Code 99457 is the appropriate code for billing of remote monitoring of physiologic data with the WCD.

• CPT code 99457 ($52/month) is defined as “Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.”
• Code 99453 ($19 one-time fee) is used to report the initial setup of equipment and patient education. Since this is performed by representatives of the manufacturer of the wearable cardioverter defibrillator, it is not billable.
• Code 99454 ($64) secures remuneration for the provision of equipment needed to facilitate remote monitoring. Since the wearable cardioverter defibrillator is reimbursed as durable medical equipment, it is not separately billable.

The new CPT codes list “weight, blood pressure, pulse oximetry, respiratory flow rate” as examples of physiologic data variables that qualify for remote monitoring. In the 2019 Physician Fee Schedule, Medicare indicated that clarification regarding which additional data variables qualify will be provided in the future. Medicare officials have subsequently clarified that ECG derived physiologic data, such as heart rate, also qualifies under code 99457.

CPT 2019 Guidelines:

• Twenty minutes or more of clinical staff/physician/other qualified health care professional time must be provided in a calendar month to qualify for billing.
• A live, interactive communication with the patient/caregiver must take place during the month such as a phone call or follow-up appointment.
• Do not count any time in a day when the physician or other qualified health care professional reports an evaluation and management service (face-to-face patient visit).
• Remote physiologic monitoring may be reported during the same month as chronic care management and transitional care management. However, it is not appropriate to double bill for time. Any minute can only be credited toward the time requirement of one of the services: remote physiologic monitoring, transitional care, or chronic care management.

Medicare Guidelines:

• A face-to-face visit must have been rendered within the year preceding the initiation of remote physiologic monitoring, which could include a hospitalization, discharge follow-up appointment, etc.
• The 2019 Physician Fee Schedule establishes that the service must be provided when the billing provider (eg, MD, NP, PA) is in the office suite, meeting the “direct supervision” requirement.
• There should be documentation in the medical record that supports the rendition of this service; including 20 minutes or more of monitoring/management activities.
• According to Medicare, “if the description of the procedure code includes 30 days of monitoring and a physician interpretation and report, then the date of service will be no earlier than the 30th day of monitoring and will be the date the physician completed the professional component of the service.”

In-Person Services:

• Code 93292 should be used, instead of 99457, when reporting in-person review and interpretation of wearable cardioverter defibrillator data.
• CPT code 93292 is defined as “Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; wearable defibrillator system.”
  • An example of an interaction in which 93292 would be billable is a clinician printing out a report from the online system and reviewing the data with a patient during a follow-up visit.
  • Note: code 93292 must be performed by a physician or other qualified healthcare professional, whereas 99457 can be performed by clinical staff as well.
• Medicare bundles 99457 (remote $52) into 93292 (in person $41), and therefore, codes 99457 and 93292 cannot be reimbursed during the same billing cycle.

Note: Payment rates were obtained from the 2019 Medicare Physician Fee Schedule.

Sample Case

Figure 1 is an example of routine activities that could be eligible for reimbursement under codes 99457 and 93292 for a newly diagnosed heart failure patient with reduced ejection fraction who was prescribed a WCD for 3 months. Remote monitoring may start as soon as the patient is fitted with a WCD. As long as the service requirements described above are met, it is appropriate to report the remote monitoring code (99457) at the end of each 30-day remote monitoring period. When WCDs are interrogated in person, code 93292 is the appropriate code to report.

Updates in Remote Patient Management: New Code, Less Supervision for 2020

On November 1, 2019, the Centers for Medicare and Medicaid Services (CMS) released the 2020 Medicare Physician Fee Schedule Final Rule, which provides an update on payment policies, rates, and other provisions for services on or after January 1, 2020.

Regarding chronic care remote physiologic monitoring (RPM) services, the 2020 Physician Fee Schedule increases reimbursement and decreases supervision requirements. According to the 2020 Physician Fee Schedule, RPM services “involve the collection, analysis, and interpretation of digitally collected physiologic data, followed by the development of a treatment plan, and the managing of a patient under the treatment plan.”¹ Therefore, in order to report code 99457, clinical staff, physicians, or other qualified professionals must provide these services for at least 20 minutes in a calendar month and have interactive communication with the patient.

RPM services might be provided to a heart failure patient who is using a wearable cardioverter defibrillator (WCD). Data captured by the WCD and posted to an online patient management system can be used to monitor the patient’s health status and response to therapy during the first few months following a cardiac event. RPM services could also be facilitated with physician-provided equipment (separately billable with code 99454).

In addition, a new RPM code was introduced in the 2020 Physician Fee Schedule. Code 99458 is used to report an additional 20 minutes of RPM after the initial 20 minutes. This code would be reported in addition to 99457 if a total of 40 minutes was spent providing the services described by the codes in a calendar month. At .61 work relative value units (RVUs), the additional 20-minute code is valued the same as the initial 20-minute code.

The 2020 Physician Fee Schedule also reduced the physician supervision requirement for RPM services from “direct” to “general.” Now, clinical staff can provide RPM services when there is no physician in the office.

The changes in the 2020 Physician Fee Schedule make RPM more attractive than ever. Now, payment is not limited to the first 20 minutes of time spent providing the service, and a physician is no longer required to be in the office when the services are rendered.

Disclosure: Mr. Collins reports a grant from ZOLL Medical for the submitted work. This was specific to the applicability of the new codes to wearable cardioverter defibrillators, and involved communicating with Medicare and securing confirmation that ECG data qualified as a physiologic data variable when monitored with external devices.

Jim Collins, CPC, CCC is the president of CardiologyCoder.Com, Inc.

1. Medicare Program; CY 2020 Revisions to Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Establishment of an Ambulance Data Collection System; Updates to the Quality Payment Program; Medicare Enrollment of Opioid Treatment Programs and Enhancements to Provider Enrollment Regulations Concerning Improper Prescribing and Patient Harm; and Amendments to Physician Self-Referral Law Advisory Opinion Regulations Final Rule; and Coding and Payment for Evaluation and Management, Observation and Provision of Self-Administered Esketamine Interim Final Rule. Federal Register. Published November 15, 2019. Available at https://bit.ly/2DTyRt1. Accessed December 6, 2019.