Cardiology Coding Alert

You'll be well on the way to coding comprehensive intracardiac electrophysiologic studies (EPS) correctly if you know two crucial things: where the physician positioned the catheters and whether he or she attempted arrhythmia induction.

Electrophysiologists perform comprehensive EPS with and without inducing arrhythmia to evaluate such problems as syncope of uncertain origin and suspected supraventricular tachycardias.

The procedure involves inserting multiple transvenous electrode catheters in the high right atrium, His bundle region and right ventricle. The physician then performs right atrial pacing and recording, His bundle recording, and right ventricular pacing and recording, according to the American College of Cardiology's (ACC) Guide to CPT 2003.

Next, the physician either assesses the conduction intervals and concludes the EPS or continues the study by inducing arrhythmias, diagnosing their mechanism, and terminating the arrhythmias by pacing methods or countershock, the ACC guide states.

Report codes in the 93619-93622 range, depending on whether the physician attempted arrhythmia and whether the study included left atrial recording or left ventricular recording and pacing. Remember to append modifier -26 (Professional component) to comprehensive EPS and add-on codes if the physician is performing the procedure in a facility.

Be sure to check National Correct Coding Initiative (NCCI) edits because NCCI often bundles EPS codes, says Sandy Fuller, CPC, a cardiology coding and reimbursement specialist in Abilene, Texas.

Coding experts offer the following tips for reporting comprehensive EPS codes correctly:

When the physician indicates that he or she placed three catheters one in the right atrium, one in the right ventricle and one in the His bundle report 93619 (Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted induction of arrhythmia), says Anne C. Karl, RHIA, CCS-P, CPC, a coding and compliance specialist with the St. Paul Heart Clinic in Mendota Heights, Minn.

"In this study, the physician is recording the electrical signals in the three noted areas and performing pacing within the right atrium and right ventricle," Karl says. "There will not be an attempt to induce an arrhythmia."

Moreover, remember that 93619 includes the services represented by codes 93600 (Bundle of His recording), 93602 (Intra-atrial recording),93610 (Intra-atrial pacing) and 93612 (Intraventricular pacing),so you should not report these codes with 93619, the ACC coding guide states. In addition, you should not report 93618 (Induction of arrhythmia by electrical pacing) or 93620-93622 with 93619, CPT says, because 93619 is a comprehensive procedure that does not include arrhythmia induction.

If you use the comprehensive EP codes (93619-93620), you cannot use the unbundled codes also, says Rebecca Sanzone, CPC, billing manager for Midatlantic Cardiovascular Associates of Baltimore.

On the other hand, if the documentation for the EPS does not include all of the components described by 93619, you should report these individual codes rather than 93619, says Brian Outland, CPC, CCS, coding and reimbursement specialist with the North American Society of Pacing and Electrophysiology (NASPE).

For example, if the physician indicates that he performed right atrial pacing and recording and His bundle recording with attempted induction of arrhythmia, you would code 93600, 93602 and 93618 rather than 93619, Outland says. In addition, if a patient has atrial fibrillation and the physician couldn't pace or record from  the atrium and performed only right ventricular recording, you would bill 93600, 93603 and 93618, he adds. If you report 93618, make sure the procedure note indicates that the physician induced arrhythmia, he says.

If the physician attempts arrhythmia stimulation during a comprehensive study, 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) and append modifier -26.

The only difference between reporting 93619 and 93620 is that the physician will attempt to induce an arrhythmia by programmed stimulation, Fuller says. The arrhythmia induction does not have to be successful to report 93620.

To eliminate any confusion regarding the types of pacing and recording included in 93620, CPT revised the code in 2003, placing the pacing descriptions after the semicolon for emphasis, according to CPT Changes 2003: An Insider's View.

Code 93620 includes the services described by 93619 and 93618, so you would not report these codes, or 93600, 93602, 93610 and 93612, with 93620, CPT states.

When the comprehensive EPS also includes left atrial pacing and recording from the coronary sinus, you should add +93621 (... with left atrial pacing and recording from coronary sinus or left atrium [list separately in addition to code for primary procedure]) to 93620-26.

The key to using 93621 is whether the physician places an additional catheter within the coronary sinus, which is a vein that originates on the wall of the right atrium and wraps around the posterior side of the heart's left side, Karl says. This will allow recording and pacing of the right atrium.

For instance, the physician may need to record from the coronary sinus or left atrium to accurately diagnose arrhythmia in patients with supraventricular tachycardia or atrial fibrillation, the ACC's coding guide says.

You should report +93622 (... with left ventricular pacing and recording [list separately in addition to code for primary procedure]) in addition to 93620 when the cardiologist performs left ventricular recording and pacing, Fuller says.

Placing an additional catheter within the left ventricle requires an arterial access point, Karl says. Cardiologists place all of the other catheters in the comprehensive EPS by venous access points. So you should look for indications of arterial access in the operative note to support adding 93622 to 93620.

A patient may have five catheters placed (right atrium, right ventricle, His bundle, coronary sinus, and left ventricle) and an attempted arrhythmia induction. In this situation you would report 93620-26, 93621-26 and 93622-26, Karl says.

Frequently, patients undergoing comprehensive EPS receive intravenous agents to induce arrhythmia, Fuller says. If this is the case, you should add +93623 (Programmed stimulation and pacing after intravenous drug infusion [list separately in addition to code for primary procedure]) to the appropriate comprehensive code, such as 93620. As with the other comprehensive EPS codes, append modifier -26 to 93623 because the physician performs the procedure in a facility.

Check the report for indications that an IV medication such as Isuprel was used for attempted arrhythmia induction, Karl says. If the documentation shows that programmed stimulation occurred after drug infusion, you would add 93623 to 93620.

Often, if the physician induces tachycardia during an EPS, he or she will perform mapping, which creates a multidimensional depiction of the tachycardia by recording electrograms from multiple catheter sites in the heart, CPT states.

When the physician performs three-dimensional mapping, report +93613 (Intracardiac electrophysiologic 3-dimensional mapping [list separately in addition to code for primary procedure]) in addition to 93620.

Watch for wording in the report that will let you know whether to bill for 3-D mapping, says Terri Davis, CPC, coding supervisor for the internal medicine department at the University of Oklahoma College of Medicine

Davis says electrophysiologists advised her to look for 3-D product names such as Biosense, Carto and EnSite to report 93613. If a 3-D product name is not in the report, she uses +93609 (Intraventricular and/or intra-atrial mapping of tachycardia site[s] with catheter manipulation to record from multiple sites to identify origin of tachycardia [list separately in addition to code for primary procedure]) in addition to 93620.

Remember that you can report only one mapping code per EPS session, Outland says. If the physician performs conventional mapping (93609) and doesn't get all the information he needs and does 3-D mapping, he can only code 93613 for the 3-D mapping, he says.