Cardiology Coding Alert

There is no code for defibrillation or cardioversion administered to patients in an emergency situation. The service is not supposed to be billed separately because it is considered part of the larger service that often accompanies it, such as cardiopulmonary resuscitation, emergency department (ED) evaluation and management (E/M) services, critical care services, cardiac catheterization, implantable-cardio defibrillator (ICD) implantation, other electrophysiological procedures or at the end of open heart surgery.

The presence of a code for elective cardioversion, however, as well as the proliferation of a variety of incorrect theories about how to bill the service and get it paid, has perplexed many cardiology coders. Their confusion likely is increased by authoritative coding advice that incorrectly contrasts only defibrillation as emergent and cardioversion as always elective.

When the Service Is Performed

An individual may require emergent electric shock if he or she experiences episodes of ventricular fibrillation (VF) or ventricular tachycardia (VT). In addition, patients with supraventricular tachycardia (SVT) or atrial fibrillation (AF) also may require emergent electric shock.

Patients with VF require defibrillation, which involves the delivery of an electrical impulse to the heart to interrupt abnormal rhythms and allow normal sinus impulse and electrical conduction to resume. On the other hand, patients with VT require cardioversion, in which the electrical shock that is administered is synchronized to an ECG. Patients with SVT or AF also require synchronized shock (i.e., cardioversion).

The defibrillation for VF and the cardioversion for the VT, SVT or AF that is performed emergently contrasts significantly with elective cardioversion, which may be performed to treat AF and atrial flutter on a planned basis, possibly after the failure of anti-arrhythmic drugs to convert the patient chemically.

In this procedure (92960, cardioversion, elective, electrical conversion of arrhythmia; external), the patient is given either a sedative or anesthetic, after which one or more synchronized electric shocks are administered and the patients heart is monitored to ensure that the rhythm has stabilized.

The difference between the two services is emphasized in an article in the summer 1993 edition of CPT Assistant, published by the American Medical Association (AMA), which also created and maintains the CPT system. The article contrasts elective cardioversion only with emergent defibrillation and doesnt mention emergent cardioversion. In addition, part of the description of the elective cardioversion procedure if the patient is hemodynamically unstable actually describes emergency cardioversion.

Coders may be confused about how to code the delivery of a synchronized emergent shock (commonly referred to as cardioversion not defibrillation) to hemodynamically unstable patients, or those with VT, SVT or AF. Consequently, coders may use (incorrectly) the nearest code available, i.e., 92960.

Note: Internal cardioversion (92961) also is an elective procedure typically performed on patients who require the device delivering the synchronized shock to be placed internally, because they are so large that an externally delivered electrical impulse is unable to deliver enough electrical current to the heart.

Whether defibrillation or emergent cardioversion has been performed, the same coding principles apply. No code exists to describe the delivery of an emergent electric shock performed in isolation. Therefore, it is incorrect to use an unlisted code, such as 93799 to bill for this service. Many commercial carriers do not even recognize this unlisted code, says Rebecca Sanzone, CPC, assistant billing manager with Mid-Atlantic Cardiology, a
47-cardiologist practice in Baltimore, Md.

Modifier -22 (unusual procedural services) should not be added to 92960. This modifier is used correctly to indicate unusual (i.e., more complicated or time-consuming) procedures, and the automatic review triggered by modifier
-22 will only tell carriers that the defibrillation/ cardioversion was emergent, not more complex.

If the emergent shock was delivered to the patient by a cardiologist during the course of a consult, only the consult should be billed. This may boost the level of decision-making by the cardiologist, but that doesnt necessarily mean the level of E/M will increase, Sanzone says, noting that determining the level of a consultation requires consideration of all three E/M components (history, examination and medical decision-making).

Cardiopulmonary Resuscitation and Critical Care

Although emergent defibrillation/cardioversion cannot be billed separately, these services typically are not performed in isolation. Therefore, the procedures or services that accompany it may be billable, says Cynthia Swanson, RN, CPC, a coding and reimbursement specialist with Seim, Johnson, Sestak & Quist, a consulting and accounting firm in Omaha, Neb.

In other words, if the defibrillation/cardioversion was delivered during the course of a cardiac catheterization or electrophysiological study, those procedures may be billed. Similarly, if it was performed during the cardiopulmonary resuscitation of a patient, code 92950 would be billable even in the context of critical care services as long as the duration of the care met critical care guidelines and the CPR time was reported separately, Swanson says.

For example, an ambulance brings a patient with severe chest pain to the ED, where he is placed on the heart monitor. The patient goes into cardiac arrest and his heart stops. The patients cardiologist is called into the ED and directs CPR activity. The cardiologist assesses and bags the patient, compresses his chest and then performs an emergency cardioversion.

In this situation, the cardiologist would code the services provided to the patient as critical care services, as long as 30 minutes or more were spent providing care to the patient, Swanson says. In addition, because CPT critical care guidelines state that any services performed that are not listed specifically as included in critical care may be billed separately, the CPR which includes the cardioversion, is billable, she says.

Note: CPT 2000 critical care guidelines on page 22 state: The following services are included in reporting critical care when performed during the critical period by the physician(s) providing critical care: the interpretation of cardiac output measurements (93561, 93652), chest x-rays (71010, 71020), blood gases, and information data stored in computers [e.g., ECGs, blood pressures, hematologic data (99090)]; gastric intubation (91105); temporary transcutaneous pacing (92953); ventilator management (94656, 94657, 94660, 94662); and vascular access procedures (36000, 36410, 36415, 36600). Any procedures performed which are not listed above should be reported separately.

Cardiology practices should check with their carriers, however, before billing both services because conflicting advice can be found on this subject. For example, the American College of Cardiology Guide to CPT Coding states the opposite: Code 92950 should not be reported if cardiopulmonary resuscitation was performed in the setting of critical care services.

When billing 92950 and critical care services on the same day, time spent on CPR may not be included as part of the total critical care time claimed, Swanson says. In other words, if the cardiologist spent 10 minutes directing CPR and 20 minutes on critical care, only 92950 could be billed because the 30-minute minimum requirement for critical care services was not met, and the 10 minutes on CPR cannot be included.

To avoid confusion on the part of the carrier, beginning and ending times for both the CPR and the critical care should be documented carefully.