Cardiology Coding Alert

Electrophysiology (EP) studies can include ablations, but these procedures might not jump out at you as you wade through lengthy EP reports. Knowing what to look for and how to code ablations will ethically add to your cardiology practice's revenue.

Frequently, during an EP study, electrophysiologists induce or attempt to induce cardiac arrhythmias by electronic stimulation, sometimes with the assistance of intravenous agents. Once the physician identifies the part of the heart causing the arrhythmia, he occasionally places an ablation catheter adjacent to those cardiac cells and "ablates" the cells by delivering highly focused heat, cold or radiofrequency energy to destroy the nerve cells causing the arrhythmia, says Jerome Williams Jr., MD, FACC, a cardiologist with Mid Carolina Cardiology in Charlotte, N.C.

Physicians also perform ablations to interrupt extra electrical "pathways" in the heart, such as atrioventricular (AV) node re-entry or accessory pathways, which occur in Wolff-Parkinson-White syndrome, Williams says.

Coding ablations can be tricky, but these five expert tips will have your claims cleared up in no time.

The first thing you should know is that you should report ablation codes 93650-93652 separately from EP study codes in the 93600-93623 range when physicians perform ablations on the same day as an EP study.

Why: In this situation, ablations are separate procedures. Moreover, when you report catheter ablation, "code 93650, 93651, and/or 93652 should be reported once to describe ablation of cardiac arrhythmias, regardless of the number of arrhythmias ablated," CPT states.

Specifically, report 93650 (Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement) when the EP physician performs an AV node ablation to correct conduction abnormalities in the AV pathway.

You should bill 93651 (Intracardiac catheter ablation of arrhythmogenic focus; for treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathways, accessory atrioventricular connections or other atrial foci, singly or in combination) for supraventricular tachycardia (SVT) due to dual AV nodal re-entry pathways, accessory atrioventricular connections or other atrial foci. "Supraventricular" indicates arrhythmias arising above the ventricles.

When the physician performs catheter ablation for ventricular tachycardia, report 93652 (... for treatment of ventricular tachycardia).

Second, make sure the documentation clearly identifies the ablation target site.

Why: To choose the correct code, you'll need to know the exact ablation target site, says Terri Davis, CPC, coding supervisor for the internal medicine department at the University of Oklahoma's College of Medicine. The documentation should specify the site. If it doesn't, the physician will need to provide this information, she says.

Example: A patient with Wolff-Parkinson-White syndrome (426.7) and paroxysmal supraventricular tachycardia (427.0) previously had a diagnostic EP study that indicated the left free wall accessory pathway as the tachycardia's source, which the physician documented in the EP report. During the ablation procedure, the physician places a catheter retrogradely across the aortic valve, performs programmed atrial and ventricular stimulation, and ablates the accessory pathway.

Solution: In this instance, you would report 93651 because the physician ablated an atrioventricular accessory pathway.

You'll use ablation codes only once, regardless of the number of ablations the physician performs at a specific site.

For instance, if the physician ablates more than one area of the supraventricular region (the area above the ventricles), report 93651 once. The relative value units for 93651 compensate for the occasional case when the physician must ablate more than one pathway in this region. In other words, if a patient has both AV nodal reentrant tachycardia and a concealed bypass tract and the physician ablates both simultaneously, report 93651 for the procedure, even though more than one area received ablation.

Code 93650 for AV node ablation includes the temporary pacer placement, so don't report this separately. If the physician inserts a permanent pacemaker during the ablation procedure, however, you would report this separately. When the AV node ablation does not include temporary pacing, you can still bill 93650.

Finally, do not report 93527 (Combined right heart catheterization and transseptal left heart catheterization through intact septum [with or without retrograde left heart catheterization]) in addition to 93651 or 93652 when physicians choose a transseptal rather than a retrograde aortic approach to access the left side of the heart.

Why not: The introductory section to CPT's electrophysiology codes states, "Intracardiac electrophysiologic studies (EPS) are an invasive diagnostic medical procedure which include the insertion and repositioning of electrode catheters ..." and "catheter insertion and temporary pacemaker codes are not additionally reported."

According to the March 2007 Cardiology Coalition Membership Newsletter, both GroupHealth Inc. and Noridian have paid attention to this direction. Their policies prevent additional reimbursement for a left heart catheterization done for reasons other than hemodynamic evaluation or angiography. Therefore, you won't have separate reimbursement with electrophysiologic or pacing studies.

On the other hand, you can recoup extra payment for the work involved with transseptal puncture and the complex series of ablations your cardiologist uses to treat atrial fibrillation. CMS recommends that you append modifier 22 (Unusual procedural services) to 93651 and 93652 to obtain additional payment for a transseptal puncture during ablation.

Although such claims require documentation and may prompt automatic review, carriers will likely pay more for the service if the physician's procedure notes clearly indicate that he took the transseptal approach.

Don't forget: Include a short letter that explains in simple terms why the transseptal approach was required, how much additional work the physician performed (compared to a routine ablation) and the added risk involved in performing such a procedure. Also include a copy of the op note with the claim, coding experts say.

Remember to consult your local medical review policies (LMRPs) and third-party insurers regarding the appropriate method for reporting transseptal-approach ablation procedures.