Cardiology Coding Alert

ECMO, TEE, and cardiac devices come under the spotlight in the latest edits.

The most recent Correct Coding Initiative (CCI) edits, effective April 1, continue to add rules for proper reporting of new-for-2015 codes, including extracorporeal membrane oxygenation (ECMO), transesophageal echocardiography (TEE), and subcutaneous implantable cardioverter defibrillator (S-ICD) services. Here’s the rundown.

1. Limit ECMO/ECLS Cannula Insertion Codes

CCI added edits for extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS). These edits bundle the various forms of cannula insertion, preventing you from reporting more than one insertion code at an encounter. 

The general rule these bundles follow is that percutaneous insertion bundles into open insertion and peripheral insertion bundles into central insertion. All of the edits have a modifier indicator of 1, so you can override the edits with a modifier when appropriate. 

2. Take TEE Code Out of ECMO and Endograft Claims

Also be alert to edits for new TEE code 93355 (Echocardiography, transesophageal [TEE] for guidance of a transcatheter intracardiac or great vessel[s] structural intervention[s] [e.g.,TAVR, transcathether pulmonary valve replacement, mitral valve repair, paravalvular regurgitation repair, left atrial appendage occlusion/closure, ventricular septal defect closure] [peri-and intra-procedural], real-time image acquisition and documentation, guidance with quantitative measurements, probe manipulation, interpretation, and report, including diagnostic transesophageal echocardiography and, when performed, administration of ultrasound contrast, Doppler, color flow, and 3D).

ECMO/ECLS again: Code 93355 bundles into new ECMO/ECLS codes 33957-33959, 33962-33966, 33969, 33984-33986, and 33988-33989 with a modifier indicator of 1, so you can override the edits with a modifier when the TEE is distinct from the ECMO/ECLS service.

Endograft planning: The other code that 93355 bundles into is new code 34839 (Physician planning of a patient-specific fenestrated visceral aortic endograft requiring a minimum of 90 minutes of physician time).

Recall that CPT® guidelines prevent you from reporting endograft planning code 34839 in conjunction with the endovascular repair (34841-34848) when the physician performs 34839 “on the day before or the day of the fenestrated endovascular repair procedure.” Code 93355 is already bundled into repair codes 34841-34848. All of these edits have a modifier indicator of 1.

CCI tip: The basic rule is that edits apply to services reported by a single physician for a single patient on the same date. So while CCI bundles 93355 with a lot of codes, including more than those discussed here, if your cardiologist provides all components of the 93355 service and another physician performs the intervention for the patient, you may be able to report 93355 for your cardiologist.

3. Don’t Mix Programming/Interrogation Eval With EP Eval

The latest round of edits prevents you from reporting S-ICD in-person evaluation with the electrophysiologic (EP) evaluation codes 93640-93642. These edits have a modifier indicator of 1, so you may override them with a modifier in the rare case that the cardiologist performs both as distinct services on the same date. 

For the edits, the column 1 codes are for EP evaluation:

• 93640, Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement

• 93641, … with testing of single or dual chamber pacing cardioverter-defibrillator pulse generator

• 93642, Electrophysiologic evaluation of single or dual chamber transvenous pacing cardioverter-defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters).

The column 2 codes that bundle into the column 1 codes are for in person S-ICD evaluation:

• 93260, Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; implantable subcutaneous lead defibrillator system

• 93261, Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; implantable subcutaneous lead defibrillator system.

Keep in mind: There is a separate EP evaluation code for S-ICDs, 93644 (Electrophysiologic evaluation of subcutaneous implantable defibrillator [includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters]). CCI also has edits for 93260, 93261, and 93644. 

S-ICD is a growing trend, so you should familiarize yourself with the codes and rules, suggests Christina Neighbors, MA, CPC, CCC, Coding Quality Auditor for Conifer Health Solutions, Coding Quality & Education Department.

4. Make Room for More Subcutaneous/Transvenous Edits

S-ICD EP evaluation code 93644 takes the column 1 spot in some new edits. These edits also have a modifier indicator of 1 and basically keep you from reporting transvenous ICD evaluations with subcutaneous ICD EP evaluation.

The column 2 codes are:

• 93282-93284, Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional … transvenous implantable defibrillator system
• 93287, Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure, or test with analysis, review and report by a physician or other qualified health care professional; single, dual, or multiple lead implantable defibrillator system

• 93289, Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; single, dual, or multiple lead transvenous implantable defibrillator system, including analysis of heart rhythm derived data elements.

5. Think Twice About Recording and Pacing Codes

Finally, the most recent round of edits ensures you don’t report EP recording and pacing component codes with cardiac device insertion, repositioning, and replacement codes.

Indicator 0: EP recording and pacing codes 93600, 93602, 93603, 93610, 93612 bundle into the following codes with a modifier indicator of 0, meaning you can’t override the edits with a modifier:

• Epicardial electrode insertion: 33202-33203

• Single to dual chamber pacemaker upgrade: 33214

• Electrode repositioning: 33215, 33226, 33273

• Pulse generator removal and replacement: 33227-33229, 33262-33264.

Indicator 1: Those same recording and pacing codes (93600, 93602, 93603, 93610, 93612) bundle into the following services with a modifier indicator of 1, so you may override the edits when appropriate:

• System insertion: 33207, 33208, 33249, 33270

• Generator insertion: 33212, 33213, 33221, 33230, 33231, 33240

• Electrode insertion: 33206 (which has a previously existing edit with 93602), 33216, 33217, 33224, +33225, 33271.

Temporary PM, too: Pacing and recording codes 93600, 93602, and 93603 also bundle into temporary pacemaker codes 33210-33211 with a modifier indicator of 1.

The recording and pacing codes are component codes, rather than complete studies. You’re unlikely to see physicians perform those component codes with the listed device services, especially the services for patients with existing devices, Neighbors notes. Before trying to override the edits with indicator 1, double check to be sure the service is reportable and to confirm whether a comprehensive code is more appropriate.