Cardiology Coding Alert

Electrophysiology (EP) studies can include ablations, but these procedures might not jump out at you as you wade through lengthy EPreports. Knowing what to look for and how to code ablations will mean more money for cardiology practices.

When physicians perform diagnostic EPand ablations on the same day, you should report ablation codes 93650, 93651 and 93652 separately from the EPcodes in the 93600-93623 range. (See "Look at the Whole Picture When Coding EP Studies" in the April 2003 Cardiology Coding Alert for more on EP.)

Typically, during EP, electrophysiologists induce or attempt to induce cardiac arrhythmias either by electronic stimulation or through intravenous agents.

Once the physician identifies the part of the heart causing the arrhythmia, he or she places an ablation catheter adjacent to those cardiac cells and "ablates" the cells by delivering highly focused heat to destroy the nerve cells causing the arrhythmia, says Jerome Williams Jr., MD, FACC, a cardiologist with Mid Carolina Cardiology in Charlotte, N.C.

The heat is delivered during ablations by any of several methods, including direct current, radiofrequency, ultrasound and freezing, according to the North American Society of Pacing and Electrophysiology's (NASPE's) CPT Coding Guide for Electro-physiology and Pacing Procedures 2003-2004.

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.

You can report ablations performed at the same time as an EPstudy because they are separate procedures, says Brian Outland, CPC, CCS, coding and reimbursement specialist with NASPE.

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 EPphysician 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).

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 College of Medicine. The documentation should specify the site. If it doesn't, the physician will need to provide this information, she says.

For example, a patient with Wolff-Parkinson-White syndrome (426.7) and paroxysmal supraventricular tachycardia (427.0) had a diagnostic EPstudy previously that indicated the left free wall accessory pathway as the source of the tachycardia, 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. In this instance, you would report 93651 because the physician ablated an atrioventricular accessory pathway.

When the EP physician performs an AV node ablation, the procedure creates complete heart block, which makes the patient permanently pacemaker-dependent. Without AV nodal conduction, no electrical impulse will travel to the ventricles to stimulate contraction, Williams says. This will result in severe bradycardia and possibly death unless the physician implants a pacemaker, he adds.

Moreover, AV node ablation may require temporary pacing prior to the placement of the permanent pacemaker. For instance, a patient with chronic atrial fibrillation (427.31) who has not responded to medications undergoes AV ablation. As part of the procedure, the physician inserts a transvenous catheter in the right ventricle (RV), which is used for temporary pacing. You should report 93650 for the AV ablation and pacing when the intent is to create a complete heart block, Davis says.
Code 93650 includes the temporary pacer placement, so you would not code this separately, according to the American College of Cardiology's 2003 coding guide. If the physician inserts a permanent pacemaker at the same time, however, you would report 33208 (Insertion or replacement of permanent pacemaker with transvenous electrode[s]; atrial and ventricular) for the permanent pacer placement in addition to 93650. If the physician inserts electrode leads for single or dual chamber pacing cardioverter-defibrillator, report 33249 (Insertion or repositioning of electrode lead[s] for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator).

Although AV node ablation includes temporary pacing, this may not be a critical part of the service, coding experts say. The EP may insert a permanent pacemaker prior to the AV node ablation, or the patient may already have a pacemaker in place. Remember that you can still bill 93650 if the procedure does not involve temporary pacing, says Jim Collins, CHCC, CPC, president of Compliant MD Inc. and compliance manager for several cardiology groups nationwide.

If the physician ablates more than one area of the supraventricular region (the area above the ventricles), report 93651 once.

Depending on carrier instructions or your local medical review policy (LMRP), you would link 93651 to such diagnosis codes as 427.31 for atrial fibrillation, 427.32 for atrial flutter, or 427.0 for supraventricular tachycardia, Davis says.

The relative value units for 93651 "compensate for the occasional case" when the physician must ablate more than one pathway in this region, according to the ACC's guide. If, for example, a patient has both AV nodal 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.

For ventricular tachycardia diagnoses, you would link 427.1 (Paroxysmal ventricular tachycardia) to 93652 because the description specifies treatment for this condition, Davis says. Bill 93652 once, even if the physician ablates more than one ventricular site.

In addition, coding experts suggest that 93651 may be appropriate for billing pulmonary vein ablations. Because the procedure involves circumferential ablation all around the outside of the pulmonary vein to isolate the abnormal beats, and the vein is in the region above the ventricle, the supraventricular ablation code (93651) appears to be the most appropriate, Outland says.

When physicians must access the left atrium for ablation in that region, this involves extra work, so coders should know how to report this.

Now, there is no CPT code for ablations that involve a transseptal puncture, which accesses the left side of the heart from the right side at the level of the atria. But NASPE and the ACC advise that you bill 93527 (Combined right heart catheterization and transseptal left heart catheterization through intact septum [with or without retrograde left heart catheterization]) and 93651 or 93652, as appropriate, to reflect the extra work.

If you report 93527 when physicians choose a transseptal rather than a retrograde aortic approach to access the left side of the heart, you should make sure that the procedure complies with "all aspects of reporting and  performance related to catheterization, including pressure measurements," according to NASPE's 2003 coding guide.

In the absence of pressure information and other catheterization-specific data, you would not report 93527. Instead, NASPE and CMS recommend that you append modifier -22 (Unusual procedural services) to 93651 and 93652 to obtain additional payment for a transseptal puncture during ablation, Outland says.

Although such claims require documentation and may prompt automatic review, carriers are likely to pay more for the service if the physician's procedure notes clearly indicate that he or she took the transseptal approach. Any claim that includes modifier -22 should be accompanied by a short letter that explains in simple terms why the transseptal approach was required, indicates how much additional work the physician performed (compared to a routine ablation) and notes the added risk involved in performing such a procedure. Also include a copy of the operative note with the claim, coding experts say.

Remember to consult your LMRPs and third-party insurers regarding the appropriate method for reporting transseptal-approach ablation procedures.

When an ablation requires the presence and skill of two EPs, such as during unusually complex or multiple ablations, append modifier -80 (Assistant surgeon) to 93650-93652 if the physicians perform the procedure in a nonacademic hospital, the ACC guide says.

Append modifier -82 (Assistant surgeon [when qualified resident surgeon not available]) when the physicians perform the ablation in a teaching hospital. The documentation should specify that the procedure required an assisting physician, the ACC says.