G695

PDF page 25 / GP11

Payment for Diagnostic and Therapeutic Services Rendered at a Hospital
  The technical component of a diagnostic and therapeutic service listed below and rendered in a
  hospital is payable at 86.10% of the listed fee in the column headed “T”.
  G104A, G111A, G121A, G127A, G140A, G143A, G146A, G149A, G152A, G153A, G167A,
  G174A,G181A, G209A, G284A, G308A, G310A, G311A, G315A, G414A, G440A, G441A, G442A,
  G443A,G448A, G451A, G455A, G466A, G471A, G519A, G540A, G541A, G542A, G544A, G554A,
  G570A,G574A, G582A, G585A, G647A, G648A, G651A, G652A, G654A, G655A, G682A, G683A,
  G684A,G685A, G686A, G687A, G688A, G689A, G694A, G695A, G815A, G850A, G851A, G852A,
  G853A,G854A, G855A, G856A, G857A, G858A, J301B, J304B, J324B, J327B

PDF page 430 / J16

Level 2
                                    All other monitoring devices with fewer than three skin electrodes, or that record only portions
                                    of the monitoring period or do not provide trend analysis. Minimum 12 hours monitoring.
               G654                       - technical component - 12 to 35 hours recording ................    26.45
               G655                       - technical component - 12 to 35 hours scanning.................     18.10
               G653                       - professional component - 12 to 35 hours recording ...........                    34.10
               G686                       - technical component - 36 to 59 hours recording ................    52.95
               G687                       - technical component - 36 to 59 hours scanning.................     36.25
               G656                       - professional component - 36 to 59 hours recording ...........                    51.15
               G688                       - technical component - 60 hours to 13 days recording........        79.40
               G689                       - technical component - 60 hours to 13 days scanning ........        54.40
               G657                       - professional component - 60 hours to 13 days recording ..                        68.20
               G694 - technical component – 14 or more days recording ............ 124.30
               G695 - technical component – 14 or more days scanning .............  91.45
               G696 - professional component – 14 or more days recording .......          86.80
                  Note:
                  1.Maximum one professional component, one technical recording component and one
                    technical scanning component per patient, per recording.

PDF page 431 / J17

DIAGNOSTIC AND THERAPEUTIC PROCEDURES
 ELECTROCARDIOGRAPHY (ECG)
                                                                                 T         P
          2.Where the duration of the service is more than 36 hours, claims for such services must be
            submitted using the appropriate listed code for that time duration and cannot be submitted
            using multiples of lesser time duration codes.
          3.G647, G648, G649, G694, G695 and G696 are only eligible for payment once per 30 day
            period per patient.
          4.Services related to external cardiac loop recording devices that rely solely on patient
            activation to record electrocardiographic data and do not have the capability of real-time
            rhythm analysis are not insured.
          Medical record requirements:
          In order to demonstrate that payment requirements have been met, all test reports that form
          part of the patient record under this section must include the following information: the number
          of channels recorded, whether the recording was continuous, whether it was analyzed in real
          time, post-hoc or both and other information, such as, the name of the manufacturer and the
          model of the device(s) used in the performance of the test.

Master, record 2345. Record Layout PDF, page 1.

G69520260401999999990000091450000000000000000000000000000000000000000000000

Auxiliary master fields are preserved as raw scaled values. The linked layout calls them zero-filled, but this edition contains non-zero values. They are not presented as final dollar fees or PDF units.