# Cardiac EP/Ablation coding Help



## DeeLonna (Aug 13, 2015)

Can anyone review this?  I am wondering if I can also code a 93657 with this documentation.  I am fairly new to cardiac specialty 

Recurrent atrial fibrillation, atypical flutter, with prior right atrial flutter ablation.

Procedure: EPS with ablation for Atrial Fibrillation 93656,59
Ablation for second arrhythmia 93655
Intracardiac Echocardiogram 93662

Access: RFV X 2
LFV X 2
RIJV X 1
Sedation: Moderate with Versed and fentanyl

EBL: Minimal

Rhythm or presentation: Atypical flutter
Rhythm post procedure: Sinus

Additional arrhythmias identified: None

Lesion sets performed: 1. Bilateral pulmonary vein isolation
2. Mitral isthmus line
3. Mitral annular line
4. CS ostium ablation
5. Cavo-tricuspid isthmus line

Ablation History: Refer to EP lab generated report

Intervals: AH: 125 msec
HV: 44 msec

Pre-procedure Intracardiac Echo: No effusion. No shunt. Normal LV systolic function. Normal appearing aortic, pulmonic, tricuspid, and mitral valves. No thrombus.
Post procedure intracardiac echo:No effusion. Persistent shunt. No changes.

Complications: None apparent. The patient had hypotension noted post procedure. Neither intracardiac echo nor transthoracic echo suggested effusion.

Procedure: Informed consent was obtained and confirmed. Appropriateness for moderate sedation was confirmed. The patient was taken to the EP lab where both groins and the right jugular regions were prepped and draped in the usual fashion. Venous access was obtained using US guidance after local anesthesia was obtained. 2 long SR-0 sheaths were inserted in the RFV, an 8 FR and 7 FR sheath in the LFV, and a 6 FR sheath in the RIJV. A decapolar pacing wire was advanced into the CS from the RIJV, a quadripolar catheter advanced to the RA, and hexapolar catheter to the HIS bundle region. An ACCUNAV catheter was advanced to the RA and intracardiac echo performed to visualize cardiac structures with emphasis on the intra-atrial septum. The first SR-0 was advanced over a wire into the left subclavian region adn was aspirated and flushed. A BRK transseptal needle was advanced near the tip. The catheter assembly was withdrawn in the usual fashion to engage the fossa ovalis as determined by fluoroscopic and intracardiac echo techniques. The transeptal needle was advanced into the left atrium as determined by pressure recordings and saline injection monitored by intracardiac echo. The dilator and sheath were advanced with the needle withdrawn and then the dilator withdrawn as the sheath was advanced. Heparin was administered as listed and was adjusted by ACT recordings during the procedure. The HIS bundle catheter was removed and the second SR-0 catheter similarly advanced to the left subclavian system and then in a similar fashion a second transseptal punctured was performed and sheath advanced. A ThermaCool catheter was advanced into the LA and was used to perform anatomic mapping of the left atrium and venous structures. The LASSO catheter was then advanced through the second sheath and used to augment the mapping.
Attention was then directed at ablation with the goal of bilateral pulmonary vein isolation as defined by the use of the LASSO catheter near the vein ostia. Attention was first directed at the left superior pulmonary vein and then carried in sequence to the other veins. Radiofrequency energy was delivered using the ThermCool catheter with maximal power at 35 Watts with near circumferential ablation delivered to all veins until they were felt to be isolated. Repeat mapping was performed in all 4 veins and entrance block confirmed. 
Attention was then directed at additional linear ablation with a mitral isthmus line delivered between the mitral valve and the LIPV. Linear mitral annular ablation was then delivered. Eventually, the ablation catheter was withdrawn to the right side and used to map the right atrium. RA activation appeared to be counterclockwise but was not entrained from the right side. Linear isthmus ablation was performed. The left side was then re-accessed readily with the pacing wire. Additional ablation was delivered along the proximal mitral annulus. The arrhythmia changed to a different variant which was irregular and had variable conduction to the distal CS. The patient was then sedated and cardioverted.
Catheters were then withdrawn to the right atrium. Protamine was administered and repeat intra-cardiac echo performed. All pacing wires were removed. After the ACT was low enough all sheaths were removed and hemostasis obtained using manual compression. The patient then returned to the medical unit in good condition. In recovery she was noted to have low blood pressure and low urine output. The low urine output was likely related to Foley dysfunction as bladder scan showed 500 cc of urine in her bladder. Her blood pressure normalized and she was taken to clinical observation unit in good condition


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## twizzle (Aug 13, 2015)

*EP ablation*

No, you can't bill 93657. The provider needs to state that a-fib persisted after PVI and ablation, therefore the veins were re-isolated and a further ablation performed.
Why do you have 59 on the 93656? Just interested.
The other thing you can bill for is the mapping. Haven't coded EP for a year or so but as far as I'm aware it's not/wasn't included in 93656. Unfortunately there is no indication that it was 3D mapping. I would clarify with your provider whether regular 93609 or 3D 93613 mapping. If he wants 3D he will need to improve his documentation if you're going to bill it. Otherwise just use 93619.
93656, 93655, 93609 or 93613, 93662-26
Hope this helps.


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## DeeLonna (Aug 25, 2015)

*Thank you!*

I used modifier 59 since it was a distinct separate service (as also suggested by the person assisting with my Cardiology Coding Training).  I will attempt to remove and bill w/o the 59 and see what happens. Thank you for your assistance! Cardiology is a new specialty for me and fortunately the person trying to train me is very will versed in this specialty although not certified.  The person in the cath lab at the facility is certified and helps as well but she codes the facility side which often is very different than the MD side.


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