Cardiology Coding Alert

You have to dig deep to discover allowed primary codes for mapping and programmed stim.

Applying the new 2013 electrophysiology (EP) study and ablation codes in real-world situations has revealed some twists and turns. Work through the encounter below, and pick up important pointers along the way to broaden your knowledge of these tricky new codes.

The case: For this example, assume the cardiologist provided the services listed below, and decide how to code them for a 2013 date of service. (Coding for an actual case should of course be drawn from the complete documentation and not just from a list of procedure names.)

·         Comprehensive EP study

·         3D color mapping

·         Programmed stimulation after drug infusion

·         Transseptal puncture (x2)

·         Left atrial pressure measurements to confirm access

·         Intracardiac echocardiography

·         Ablation for atrial fibrillation by pulmonary vein isolation (PVI)

Start by Selecting the Proper Primary Code

Before you begin choosing your codes for a 2013 EP service, you need to identify all services performed. Proper coding depends on this step because the new codes combine multiple services typically performed at the same encounter under a single code.

As a case in point, the first code you’ll report for the example encounter includes all of the following services in the definition text:

·         Comprehensive EP study

·         Transseptal puncture (x2)

·         Ablation for atrial fibrillation by PVI.

The appropriate code is 93656 (Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with atrial recording and pacing, when possible, right ventricular pacing and recording, His bundle recording with intracardiac catheter ablation of arrhythmogenic focus, with treatment of atrial fibrillation by ablation by pulmonary vein isolation).

Note that although the definition doesn’t specifically refer to left atrial pressure measurements, the example indicates the measurements were performed simply to confirm access. That confirmation isn’t a separately reportable service.

Put Puncture and Ablation Pointers to Work

To better understand proper use of 93656, hold on to these two pointers related to transseptal puncture and the ablation service.

Transseptal pointer: Pay attention to the inclusion of transseptal catheterization in the 93656 definition. That means for a 93656 service, you should not separately report transseptal puncture using +93462 (Left heart catheterization by transseptal puncture through intact septum or by transapical puncture [List separately in addition to code for primary procedure]).

Be sure to note that you MAY report +93462 in addition to the other two new EP study/ablation codes:

·         93653, Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording, His recording with intracardiac catheter ablation of arrhythmogenic focus; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry

·         93654, … with treatment of ventricular tachycardia or focus of ventricular ectopy including intracardiac electrophysiologic 3D mapping, when performed, and left ventricular pacing and recording, when performed.

PVI pointer: A key element of 93656 is that the physician performs PVI to treat atrial fibrillation. If the physician does not specify PVI, then 93656 would not be the appropriate code. PVI involves ablating tissue in a circle around the openings of the pulmonary veins into the left atrium. The goal is to prevent abnormal impulses from the veins reaching the heart.

If PVI is not the technique used, 93653 could be an appropriate alternative for ablation to treat atrial fibrillation. Code 93653 represents treatment of supraventricular tachycardia (SVT), and atrial fibrillation is a typical type of SVT. Supraventricular means “above the ventricles,” and the atrial chambers are above the ventricles. Other terms you may see related to supraventricular arrhythmias include atrial flutter, atrioventricular nodal reentrant tachycardia (AVNRT), atrioventricular reciprocating tachycardia (AVRT), and Wolff-Parkinson-White Syndrome (WPW).

Take a Trip Down Memory Lane With 2012 Codes

Code 93656 applies to services performed Jan. 1, 2013, or later. If the same EP study, transseptal puncture, and PVI services had been performed in 2012, you would have needed three codes.

For a 2012 comprehensive EP study, you would have reported 93620-26 (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; Professional component).

Mod 26 pointer: The 2012 code 93620 required modifier 26 to indicate you were reporting the professional component of the code only. You should not append modifier 26 to 2013 code 93656 because the code cannot be split into professional and technical components.

For atrial fibrillation ablation, the primary service code in 2012 was 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).

Because the patient required transseptal puncture, in 2012 you would have separately reported +93462. The code has a medically unlikely edit (MUE) of 1, so you would have reported a single unit even for dual transseptal punctures. Recall that +93462 should NOT be reported in addition to 2013 code 93656.

Spotting Reportable Add-On Codes Isn’t Easy

Three services from the sample encounter remain to be considered:

·         3D color mapping

·         Programmed stimulation after drug infusion

·         Intracardiac echocardiography (ICE).

Mapping: The appropriate code for 3D color mapping is +93613 (Intracardiac electrophysiologic 3-dimensional mapping [List separately in addition to code for primary procedure]).

Mapping pointer: For a 2012 service, you could expect separate payment for this code. For 2013, whether your payer will reimburse you for +93613 in addition to 93656 may depend on the payer edits.

Specifically, Medicare does not list 93656 as an acceptable primary code for +93613. The only allowed primary codes for +93613 are 93620 and 93653, according to Transmittal 2636, CR 7501, effective April 1, 2013 (www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2636CP.pdf).

The CMS listing is causing confusion because CPT® guidelines do not specifically exclude the use of +93613 with 93656, says Terry A. Fletcher BS, CPC, CCC, CEMC, CCS-P, CCS, CMSCS, CMC, President/CEO of Terry Fletcher Consulting, based in California.

What the guidelines do state is:

·         Use +93613 with 93620 and 93653.

·         Do not use +93613 with 93609 (Intraventricular and/or intra-atrial mapping …) or 93654.

Mapping also isn’t included in the 93656 code description, Fletcher says. So it’s logical to conclude that +93613 is reportable with 93656. Although you can expect Medicare to deny the code, you shouldn’t assume other payers won’t reimburse +93613 with 93656.

Programmed stim: For the programmed stimulation after drug infusion, the proper code is +93623-26 (Programmed stimulation and pacing after intravenous drug infusion [List separately in addition to code for primary procedure]).

Stim pointer: Again, you could expect separate payment for +93623 for a 2012 encounter, but CPT® and CMS currently list only comprehensive EP eval codes 93619 and 93620 as appropriate primary codes for +93623. That means 93656 is not currently listed.

CMS confirms that +93623 is not reimbursable with 93656 in Correct Coding Initiative manual, Chapter IX, Section I.29, says Christina Neighbors, MA, CPC, CCC, ACS-CA, a cardiology coding expert in Tacoma, Wash. She points to this quote added Jan. 1, 2013: “CPT® code 93623 (programmed stimulation and pacing after intravenous drug infusion) is an add-on code that may be reported per CPT® Manual instructions only with CPT® codes 93619 or 93620 (comprehensive electrophysiologic evaluation). CPT® code 93623 should not be reported for injections of a drug with stimulation and pacing following an intracardiac catheter ablation procedure (e.g., CPT® codes 93650-93657) to confirm adequacy of the ablation. Per CPT® Manual instructions, CPT® code 93623 is not intended to be reported with the intracardiac catheter ablation procedure codes, and confirmation of the adequacy of ablation is included in the intracardiac catheter ablation procedure.”

ICE: Finally, the intracardiac echocardiography (ICE) code is +93662-26 (Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation [List separately in addition to code for primary procedure]).

ICE pointer: This code offers a little good news because it is reportable for 2012 and 2013 services. Both CPT® and CMS list 93656 as an appropriate primary code for +93662, so you should not face reimbursement issues for this particular code.

Final pointer: Be sure to check the professional/technical modifier rules for these add-on codes when they’re reportable. As shown above, +93613 does not accept modifier 26, but both +93623 and +93662 do.