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Cardiology Coding Alert

Modifier Is Key for Ablation with Transseptal Puncture Reimbursement

Published on Fri Feb 01, 2002

When an electrophysiological evaluation reveals an accessory pathway, the physician may decide to perform an ablation either during or after the session. Code 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) is used to report the ablation, which typically includes placing catheters in the right atrium, the region of the His bundle, the coronary sinus and the right ventricle.
 
Although a fifth catheter is usually placed retrograde across the aortic valve to map and ablate the accessory pathway, the surgeon may have to take a transseptal approach instead and puncture the atrial wall from the right side to get the catheter to the left side where it is needed. Reimbursement for the additional work and risk involved in performing a transseptal puncture can be difficult to obtain, mainly because CPT does not have a code for this procedure.

Avoid Double-Dipping

The North American Society of Pacing and Electrophysiology (NASPE) recommends that physicians bill both 93651 and 93527 (Combined right heart catheterization and transseptal left heart catheterization through intact septum [with or without retrograde left heart catheterization]) when a transseptal approach is chosen over a retrograde aortic approach. NASPE also instructs physicians who bill Medicare carriers to append modifier -59 (Distinct procedural service) to 93651.
 
Note: The same applies to 93652 (Intracardiac catheter ablation of arrhythmogenic focus; for treatment of ventricular tachycardia): NASPE recommends reporting both 93652 and 93527 when a transseptal approach is used.
 
Unfortunately, Medicare and private carriers may accuse a physician who codes the session this way of double-dipping or fraud, says Nikki Vendegna, CPC, a cardiology coding and reimbursement specialist in Overland Park, Kan. "It is inappropriate to bill 93527 in addition to 93651, because a cardiac catheterization has not been performed," she says. "Although the catheters used to ablate the pathway may resemble what is performed in a combined right and left heart cath, the placement of these catheters is part of 93651, so to go ahead and bill 93527 as well is double-dipping and, therefore, inappropriate."
 
Vendegna also points out that the catheters are not placed for the same reason in an ablation as they are in a cardiac catheterization. "Heart caths are performed to take measurements and look for specific types of heart disease, such as coronary artery disease and cardiomyopathy. That is not the purpose of an ablation, which is performed to destroy an electrical pathway in the heart." There may not be a diagnosis to support a heart cath even if pressures are taken, she says.
 
Note: When the ablation is performed following an electrophysiological study during the same session or in different sessions on the same day, it may be necessary to provide two separate reports to the payer to prove that two separate services were performed.

Diagnosis Codes and Medical Necessity

Medical necessity can create additional problems when reporting 93527 in addition to 93651 or 93652. Cardiac catheterizations and electrophysiological ablations are performed for very different reasons, and carriers may not accept 93527 if the diagnosis code relates to an arrhythmia problem, notes Sueanne Bicknell, CPC, CCS-P, a cardiology coding and reimbursement specialist in Dallas. "It is unlikely that the diagnosis that supports an ablation will also provide medical necessity for a left-right heart cath," Bicknell says. "In most cases, patients who require a left-right heart cath, or any type of left heart cath, have significantly different problems than those who require ablation."
 
Note: One exception is paroxysmal ventricular tachycardia (427.1), which some carriers accept as a payable diagnosis for certain left heart caths.
 
Furthermore, the current Medicare fee schedule values 93527 with modifier -26 (Professional component) appended to it at 10.69 relative value units (RVUs) and 93526 (Combined right heart catheterization and retrograde left heart catheterization) with modifier -26 appended to it at 8.8 RVUs. The only difference between the two procedures is that 93527 requires puncture of the septal wall, which Medicare values at 1.89 RVUs. "There is no code for a transseptal puncture alone," Vendegna says. "Placing the catheters the other part of 93527 is already part of the ablation being performed." An ablation, meanwhile, is valued at 23.88 RVUs (93651) or 25.96 RVUs (93652). Although physicians may believe the puncturing of the septal wall is worth an additional 10.69 RVUs, this is clearly not Medicare's intent (i.e., Medicare assigned these RVUs to the entire procedure described by 93527 and not just the transseptal approach).

Obtaining Reimbursement

Vendegna and Bicknell agree that the only way physicians may appropriately obtain additional payment for a transseptal puncture during an ablation is to append modifier -22 (Unusual procedural services) to 93651 or 93652. Although such claims require documentation to be submitted and prompt automatic review, carriers are likely to pay more for the service if the physician's procedure notes clearly indicate that the transseptal approach was taken. Any claim that includes modifier -22 should be accompanied by a short letter that explains in simple terms why the transseptal approach was required, indicates how much additional work was performed (compared to a routine ablation) and notes the added risk involved in performing such a procedure.
 
Note: In spite of all the arguments presented, it has been reported that some carriers will pay for 93527 when reported at the same time as 93651 or 93652. Remember, however, that correct coding is not a guarantee of payment, and unless the policy is obtained in writing from the carrier, the extra payment for 93527 may need to be refunded.

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