Cardiology Coding Alert

Keep tabs on CPT^® guidelines and supporting diagnoses to keep your claims on track.

CPT^® 2017 shifted coding for left atrial appendage closure (LAAC) from Category III to Category I. Watch these key areas to be sure your claims for the new code make the grade.

Compare Your 2016 and 2017 Options

The descriptor for new code 33340 (Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement[s], left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation) looks a lot like the descriptor for the code available in 2016.

In 2016, you used 0281T (Percutaneous transcatheter closure of the left atrial appendage with implant, including fluoroscopy, transseptal puncture, catheter placement[s], left atrial angiography, left atrial appendage angiography, radiological supervision and interpretation).

What's different: The 2017 version adds to the 2016 version by stating that the implant involved is "endocardial" and that the angiography is included "when performed."

Don't Double Up on Transseptal Puncture Coding

Guidelines with the 2017 code help you understand what 33340 includes.

The first guideline tells you not to report 33340 together with +93462 (Left heart catheterization by transseptal puncture through intact septum or by transapical puncture [List separately in addition to code for primary procedure]).

Hint: This guideline makes sense considering the 33340 descriptor clearly includes the transseptal puncture +93462 describes.

Check Reason Before Coding Cath

The final two guidelines boil down to this: Don't report a cardiac catheterization code together with 33340 unless the two services are for different indications.

Specifically, unless (1) indications for the cath are distinct from the LAAC, and (2) any left ventricle cath occurs by a non-transseptal approach, you should not report the following cath codes with 33340:

• 93452 (LHC)
• 93453 (LHC and RHC)
• 93458-93461 (coronary angiography with cath)
• 93531-93533 (congenital cath).

You also should not report 33340 with the codes listed below unless the complete RHC is for indications distinct from the LAAC:

• 93451 (RHC)
• 93453 (LHC and RHC)
• 93456, 93460, 93461 (coronary angiography with cath)
• 93530-93533 (congenital cath).

Indications example: During an LAAC session, distinct indications for a right heart catheterization might include pulmonary hypertension, says Christina Neighbors, MA, CPC, CCC, coding quality auditor for Conifer Health Solutions.

Round Out Your LAAC Know-How

Reimbursement: In the proposed 2017 Medicare physician fee schedule, CMS had listed 13.00 work RVUs for 33340. But the final version upped the work RVUs to 14.00 to match the Relative Value Scale Update Committee (RUC) recommendation.

Coverage: CMS covers percutaneous LAAC for non-valvular atrial fibrillation (NVAF) through Coverage with Evidence Development (CED). The conditions of coverage are listed in the National Coverage Determination (NCD) manual, Chapter 1, Section 20.34 (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf).

As the NCD explains, patients with an irregular heartbeat are at increased risk of stroke, and the LAA is a possible source of stroke-causing blood clots. Blood thinners help with stroke prevention. LAAC is "an alternative to long-term anticoagulation," said Mike Mahoney, president and chief executive officer of Boston Scientific in a statement at the time the NCD was announced. Boston Scientific makes the WATCHMAN LAAC Device.

ICD-10-CM: MLN Matters MM9638 sets out billing instructions for LAAC, and states you should choose one of the following primary diagnosis codes for NVAF, based on the documentation:

• I48.0, Paroxysmal atrial fibrillation
• I48.1, Persistent atrial fibrillation
• I48.2, Chronic atrial fibrillation
• I48.91, Unspecified atrial fibrillation.

Because of the CED status, add secondary diagnosis code Z00.6 (Encounter for examination for normal comparison and control in clinical research program), which you can use to indicate "Examination of participant or control in clinical research program," according to a note in ICD-10.

Modifier: Append modifier Q0 (Investigational clinical service provided in a clinical research study that is in an approved clinical research study) to the CPT® code. »» (The MLN Matters article still refers to 0281T, so watch for an update.)

POS: Use place of service code 21 for inpatient hospital.

Trial number: Put the clinical trial number in item 23 of the CMS-1500 form (or electronic equivalent).

Resource: Check out Medicare guidance available at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9638.pdf.