Cardiology Coding Alert

If your transseptal atrial fibrillation ablation claims are falling flat because you're misidentifying them as transseptal puncture for combined diagnostic heart catheterizations cases, the skinny on these procedures will straighten out your coding.

When your cardiologist performs a transseptal puncture to do a combined (right and left) diagnostic heart catheterization, you would typically use 93527 (Combined right heart catheterization and transseptal left heart catheterization through intact septum [with or without retrograde left heart catheterization]).

Code 93527 has professional and technical parts. Therefore, you need to include modifier 26 (Professional component) for the physician portion, says Kelly Wojciechowski, CCA, coding and compliance specialist at Wheaton Franciscan Healthcare in Milwaukee.

Don't miss: With 93527-26, the doctor will frequently perform intracardiac echocardiography +(93662, Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation [list separately in addition to code for primary procedure]). The cardiologist advances a special device into the right atrium of the heart through the venous system, and once in position he does the ECG to visualize the septum and choose an optimal point at which to perform the puncture. Then he punctures through the septum, into the left atrium.

More commonly, doctors perform transseptal punctures to facilitate complex electrophysiologic procedures, such as atrial fibrillation ablations. These procedures require access to the left atrium to:

• create a pattern of ablative lesions that electrically isolate the pulmonary veins from the rest of the atrium

• interrupt abnormal electrical pathways.

"When A-fib ablation is the reason for the transseptal puncture, you should not report the transseptal puncture as a diagnostic heart catheterization," says Jim Collins, CPC-CARDIO, ACS-CA, CHCC, president of CardiologyCoder.Com Inc. in Saratoga Springs, N.Y. In the CPT book's EP procedures introductory section, numerous 93527 local coverage determinations (LCDs) and the Correct Coding Initiative (CCI) instructions clearly establish this guideline.

The most appropriate way to report transseptal punctures performed for A-fib ablations is "to attach the 22 modifier to the SVT ablation code (93651-22, 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; increased procedural services)," Collins says.

Important: To use modifier 22, you must document the time involved and list the procedural details of the transseptal puncture, says Jennifer Crowell, CPC-EMS, hospital coordinator at Spokane Cardiology in Washington. "Our physicians have also dictated a standard letter explaining the differences for an A-fib ablation including the transeptal puncture, and the high risk involved for the patient," she says.

Tip: Be prepared to appeal for extra reimbursement.

Procedure reason: Cardiologists perform transseptal procedures for diagnostic purposes or as a means to perform an intervention in an anatomic location that is difficult to reach via a routine (non-transseptal puncture) approach, says Jerome Williams Jr., MD, FACC, a cardiologist with Mid Carolina Cardiology in Charlotte, N.C.

The "septum" is the wall that separates the right and left sides of the heart. There is an atrial septum and a ventricular septum. A transseptal puncture refers to the process of accessing one side of the heart (typically the left) by first placing a catheter in the opposite side (usually the right) and puncturing across the septum (usually the atrial septum).