Informed Consent for Remote Monitoring

You have signed up for Remote Monitoring, or a “home monitoring” device. This home monitor will be assigned to your specific device and was either given to you the day after your implant, will be shipped to your home address on behalf of Dr. Ekeruo or will be given to you at your wound check after device implant.

If the monitor is mailed to you, there will be a toll-free number to call for technical set-up support. The device company tech support will walk you through setting up your monitor. You will be asked to send in an initial transmission of device data to establish your account. Our device personnel can access your transmission through a secure, password protected web server. Once the monitor is set up and the initial transmission is sent, please call us after 15 minutes to assure we received the transmission.

If your monitor was set up in the hospital or in the clinic, there is no further set up needed from you, and all you will have to do is plug in the monitor.

• An Annual Office Visit is required if we are following your monitor in remote clinic.
• If you are experiencing any problems that feel related to your heart, an arrhythmia, or your device, we encourage you to send a transmission and call the office. If data is sent via remote monitoring and there are clinical issues that need to be addressed, we will call you to review and will schedule an appointment immediately if appropriate.

• Your device data will be sent to a secure central server where our clinic staff can view it, using a password protected website on the internet.
• Our office reviews device data every business day.
• Our office will not see data sent on Saturday or Sunday until Monday morning.
• You should not use the monitor to send device data to us unless you are scheduled to do so, experiencing a problem, or if you have been instructed to do so by the clinic staff or your physician.
• Please do not send transmissions daily or weekly unless instructed to do so by your physician.
• After we review your data, if there are any clinical issues that need to be addressed, we will contact you by phone.
  • We will contact you following a normal interrogation by text message or e-mail. You may call us if you have any questions/concerns. Please note your preference below.

Our Clinic will bill your insurance company only once during each remote monitoring interval period regardless of how many transmissions we receive. If you currently have a co-pay when you have a clinic visit, we anticipate that you might be billed the same co-pay for your remote transmission.

Please note that your bill for your office visit and remote monitor billing are independent of each other. If you have questions regarding how your insurance will pay for the remote monitoring visit, please contact your insurance company. Your insurance company will ask for CPT codes to quote the charges:

Codes for a Pacemaker Remote Transmission – CPT Code 93294 & 93296 Codes for a Defibrillator Remote Transmission – CPT Code 93295 & 93296 Codes for a LINQ / CONFIRM / ILR Remote Transmission – CPT Code 93299 & 93298 Codes for ICM/ Intracardiac Heart Failure Remote Transmission- CPT Code 93297

 

** Legal Disclaimer - These codes are subject to change based on CMS guidelines **

Pacemaker & Defibrillator Remote Monitoring Billing Interval is 91 days

Implantable Loop Recorder Remote Monitoring Billing Interval is 30 days

ICM Remote Monitoring Billing Interval is 30 days

 

I have read and understand the Remote Monitoring Office Policies and agree to remote monitoring of my device.

1. If you have an emergency, please call 911.

2. If you receive a shock from your defibrillator, please call the clinic as soon as possible during business hours.

3. If you receive more than one shock from your defibrillator in a 24-hour period, please go to the nearest emergency room, and notify this clinic as soon as possible.

If you will be away from home for a long period of time (longer than 2 weeks), you can take your monitor with you. Please provide an alternate contact number for the clinic to contact you if necessary.

My physician has recommended that I monitor my implanted cardiac device by using a home monitor provided by the device manufacturer. I understand that this home monitoring is also recommended by the device manufacturer and is considered the standard of care for patients with pacemakers, implantable cardioverter defibrillators (ICDs), and implantable loop recorders (ILRs). At this time, I choose NOT to use a home monitor to remotely monitor my cardiac device.

Although the benefits of remote monitoring include faster detection of device problems and malfunction, changes in my heart rhythm, and less frequent office visits, I choose not to utilize this service. I understand that it is my responsibility to have my device periodically checked in the office. Medicare guidelines stipulate that a pacemaker can be checked in-office no more often than once every (6) six months (unless clinically indicated). An ICD can be checked every (3) three months.

If monitoring equipment has already been provided by my device manufacturer, I will make arrangements to return the equipment by calling the toll-free number provided with the equipment.

I understand that I may change my mind at any time and begin/resume home monitoring of my cardiac device by contacting the office of Virginia Arrhythmia Consultants. By signing this document, I acknowledge that my medical condition has been evaluated and explained to me by my physician. This physician has recommended the use of a home monitor. She has explained the potential benefits of such treatment and the probable risk of not following the recommended treatment, both of which I fully understand.