Cardiology Coding Alert

Practice your comprehensive electrophysiology study (EPS) coding skills by supplying codes for the following scenario adapted from an actual operative note.

Our coding experts will show you what key phrases you should have highlighted and then take you step-by-step through picking the perfect EPS codes.

Procedure: The patient arrived in the electrophysiology laboratory. All sheaths and catheters were inserted percutaneously using the Seldinger technique under conscious sedation with Propofol. The right clavicular region, right groin, and left groin were prepped and draped in the usual manner.

The physician inserted a 4# French arterial sheath into the right femoral artery for monitoring blood pressure and arterial gases. The physician inserted a 7# French deflectable tip catheter into the right subclavian vein and advanced into the coronary sinus and great cardiac vein.

The physician next inserted a 7# French deflectable tip catheter into the right femoral vein and positioned along the crista terminalis, with the tip of the catheter positioned at the ostium of the superior vena cava. He inserted a 7# French octapolar electrode catheter (2-mm spacing) into the left femoral vein and advanced it to the His bundle region. He inserted a 6# French hexapolar electrode catheter into the left femoral vein and advanced to the right atrial appendage. He next inserted a 7# French quadrapolar electrode catheter into the left femoral vein and advanced to the right ventricular base close to the His bundle for ventricular pacing.

The physician used a 7.5# French deflectable quadrapolar catheter with a 4-mm irrigated tip electrode and location sensor for the EnSite 3D mapping system, which was inserted into the right femoral vein for right atrial mapping. The patient was awakened to allow induction of tachycardia. The physician induced five macroreentrant right atrial tachycardias. Afterward, he induced programmed atrial stimulation, AT#3, which had a cycle length of 345 msec.

The report also contained appropriate measurements of the antegrade and retrograde atrioventricular nodal effective refractory periods, the A-H and H-V measurements, and details of both pacing and recording of the right atrium from the coronary sinus position.

When you're coding from a procedure note, you want to isolate key phrases.

For instance, look at this statement: "The physician inserted a 4# French arterial sheath into the right femoral artery for monitoring blood pressure and arterial gases."

Result: This statement supports billing code 36620 (Arterial catheterization or cannulation for sampling, monitoring, or transfusion [separate procedure]; percutaneous).

Note: The last paragraph is critical. The physician's stating that he simply placed catheters in the appropriate positions does not make it a diagnostic study. The report must show the details of what the physician measured.

When you read the above note, you should choose your EP codes wisely.

Step 1: Report 93620 (Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording) because the physician inserted and repositioned multiple electrode catheters, induced arrhythmia, and performed right atrial pacing and recording, right ventricular pacing and recording, and His bundle recording.

Next you should decide whether to include any add-on codes.

"With add-on codes (93621-93622), you need to pay attention whether the data from the heart is from the right or left side," says Jackie Miller, RHIA, CPC, senior consultant with Coding Strategies Inc. in Powder Springs, Ga. Important: "If your physician does left heart studies and you only code it as a right-sided study, you're missing out on additional revenue," Miller says.

Step 2: Add +93621 (... with left atrial pacing and recording ...) to 93620 for the pacing and recording from the coronary sinus and great cardiac vein. Because this code descriptor specifically states "with left atrial pacing and recording," the physician needs to include documentation that specifies both pacing and recording of the left atrium. Often, this information is lacking in EP reports. Without proof of both services, you need to add modifier 52 (Reduced services) to 93621, says Deb Ovall, CMA, CCS, CIC, outpatient coder and interventional specialist at the University of Toledo Medical Center.

Step 3: Add +93613 (Intracardiac electrophysiologic 3-dimensional mapping [list separately in addition to code for primary procedure]) to 93620 for the EnSite (3-D) mapping of the right atrium.

Step 4: You would not add +93623 (Programmed stimulation and pacing after intravenous drug infusion [list separately in addition to code for primary procedure]) to 93620 because the report does not document administration of an IV medication such as Isuprel for programmed stimulation during attempted arrhythmia induction.

In conclusion, your claim should look like this:

• 93620-26 (Professional component)

• 93621-26

• 93613

• 36620-59.

Note: A Correct Coding Initiative (CCI) edit bundles 36620 into 93620, so you'll need to apply modifier 59 (Distinct procedural service) to report 36620 separately. "The justification for the modifier is that the physician did not need arterial access for any of the procedures he performed. In other words, he did all the EP services via venous access," Miller says.