Cardiology Coding Alert

CPR and cardiac cycle synchronization offer key clues to proper coding.

Cardioversions and defibrillations can trigger claim denials if you don’t know how to distinguish between those services. With the added complication of the vaguely defined “elective” cardioversion, it’s no wonder there is often confusion.

Here are some guidelines to help you recognize each procedure so you’ll be on your way to securing proper reimbursement.

Separate Defibrillation From Cardioversion

Cardioversion is not the same thing as defibrillation, emphasizes Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a coding and billing company in Bedford, Mass.

Defibrillation, the use of an electric shock to restart or normalize heart rhythms, is always an emergency procedure, says Granovsky. The patient who receives this service has no pulse and is typically in ventricular fibrillation, or VF. The ICD-9 VF code is 427.41 (Ventricular fibrillation), and the ICD-10 code is I49.01 (Ventricular fibrillation).

On occasion, physicians also render defibrillation for patients with ventricular tachycardia (VT) when the patient has no pulse, aka pulseless VT.  For documented VT, the ICD-9 code is 427.1 (Paroxysmal ventricular tachycardia). ICD-10 includes I47.2 (Ventricular tachycardia).

Defib clues: Below are additional clues that the procedure is defibrillation, according to Granovsky:

·         The physician delivers the shock at any point in the cardiac cycle

·         There is no sedation (the patient is unconscious)

·         A medical team also renders CPR (92950, Cardiopulmonary resuscitation [e.g., in cardiac arrest]).

Pay attention to this CPR detail. If CPR was in progress, then defibrillation shocks were likely given, not cardioversion, Granovsky says.

Coding: There is no CPT^® code to report defibrillation as a procedure performed in isolation. “Defibrillation may be performed as part of critical care services, at the end of open heart surgery, during cardiac catheterization and coronary angiography, or during an electrophysiological procedure. Defibrillation is often a component of cardiac resuscitation, especially in adults. In all of these situations, defibrillation is not a separately reportable service,” states CPT^® Assistant (November 2000).

Watch Cardiac Cycle Sync for Cardioversion Clue

In contrast to defibrillation, electrical cardioversion uses energy delivered in synchronization with the cardiac cycle to convert the heart back to normal sinus rhythm. Cardioversion treats a variety of conditions, including these:

Coding: “CPT^® code 92960 [Cardioversion, elective, electrical conversion of arrhythmia, external] describes a planned elective procedure,” states the Correct Coding Initiative (CCI) manual, Chapter XI.I.3 (available from the Downloads section at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html).

A physician may perform elective cardioversion for atrial fibrillation or atrial flutter if the heart doesn’t convert back to normal sinus rhythm following administration of anti-arrhythmic drugs or if the patient is hemodynamically unstable, Granovsky explains. Elective cardioversion usually entails fasting after midnight the day before and starting an intravenous line as preparatory work. The typical setting for elective cardioversion is in an Intensive Care Unit, a Coronary Unit, or other outpatient area with appropriate equipment, such as a cardiac monitor and crash cart, he adds, in line with information given as long ago as the Summer 1993 CPT^® Assistant.

Additionally, many experts see “elective” as meaning the service isn’t required to immediately curtail an actively progressing deadly rhythm, which allows room for coding elective cardioversion that’s decided upon and performed on the same date.

For instance: Suppose a patient presents with atrial fibrillation at a rate of 180. For this patient, there are other treatment options, generally involving drugs such as Cardizem first. However, if these pharmacologic interventions fail, the physician may decide to employ cardioversion, Granovsky explains, so selecting cardioversion may be “elective” in this case.

What to look for: Documentation to suggest that the treatment was elective cardioversion would include the physician obtaining informed consent from the patient and discussing the risks and benefits of the procedure, as well as the patient potentially receiving sedation to make the procedure more comfortable. These items paint the picture that this was an elective treatment even if it wasn’t pre-scheduled.

Do this: Ask your physician to document specifically if the cardioversion was elective, Granovsky instructs.