Tips Plus More Tips for Cardiology in 2013

Part 2: Catch up on reporting of ablations and newer technology procedures.

by David Dunn, MD, FACS, CIRCC, CPC-H, CCC, CCVTC
As we learned in Part 1 of this two-part series (see “Changes Plus More Changes for Cardiology in 2013,” page 40-43, January’s Cutting Edge), the new year brings significant changes to cardiology coding. This month, we cover CPT® coding in 2013 for transcatheter aortic valve replacement (TAVR), ventricular assist devices, electrophysiology ablations, subcutaneous defibrillators, intracardiac ischemia monitoring systems, and left atrial (LA) hemodynamic monitoring systems.

Transcatheter Aortic Valve Replacement/Implantation (TAVR/TAVI)

Codes 0256T-0259T are deleted for 2013, replaced by new codes for TAVR/TAVI. To make it easier to differentiate the services, here’s a list of the new codes with abbreviated descriptors:
33361   TAVR, percutaneous femoral approach
33362   TAVR, open femoral approach
33363   TAVR, open axillary approach
33364   TAVR, open iliac approach
33365   TAVR, transaortic approach (eg, median sternotomy)
0318T   TAVR, open transapical approach (eg, left thoracotomy)
+33367 Cardiopulmonary bypass support for TAVR, percutaneous peripheral arterial and venous cannulations
+33368 Cardiopulmonary bypass support for TAVR, open peripheral cannulations
+33369 Cardiopulmonary bypass support for TAVR, central (eg, aorta, right atrium, pulmonary artery) cannulations
Here are some tips for applying these new codes correctly:

• The only currently approved device is the Sapien valve. It’s indicated for patients with severe aortic stenosis who are not surgical candidates (determined by a cardiothoracic surgeon).
• The three add-on codes for cardiopulmonary bypass (C-P bypass), when performed, are also based on approach. Only one C-P bypass code is submitted during TAVR.
• Open femoral (34812) and open brachial access (34834) are included in the TAVR codes.
• Temporary pacemaker placement for rapid pacing during TAVR, as well as catheter placements and balloon valvuloplasty, are included.
• Swan-Ganz placement and aortic/left ventricular (LV) measurements and imaging to guide and complete the TAVR are included.
• If a complete heart catheterization is performed, you may report it if no prior diagnostic study was performed or a suboptimal study is documented, or if there has been a clinical change in the patient since the prior study or during the procedure.
• Code for other percutaneous coronary/cardiac interventions that are performed and medically indicated.
• You may code for ventricular assist device or intra-aortic balloon pump (33990, 33991, 33967, 33970), if performed.
• TAVR requires two physicians to complete the procedure. Codes 33361-33365 and 0318T Implantation of catheter-delivered prosthetic aortic heart valve, open thoracic approach, (eg, transapical, other than transaortic) require modifier 62 Two surgeons for physician billing. For example, each physician would report 33361-62 for a percutaneous TAVR. The C-P bypass codes do not have this requirement.

Example: An elderly patient with severe aortic stenosis, who is not a surgical candidate, presents for a TAVR procedure. This is performed with C-P bypass via femoral cut-downs and rapid pacing with a temporary pacer. The TAVR is performed via percutaneous approach.
Correct codes would be:
33361   Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach
+33368 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with open peripheral arterial and venous cannulation (eg, femoral, iliac, axillary vessels) (List separately in addition to code for primary procedure)
Note: Do not report the temporary pacemaker.

Ventricular Assist Device (VAD)

Codes 0048T and 0050T for VAD are deleted and replaced by new, Category I CPT® codes. For easy reference, here are abbreviated descriptors:
33990   Insert VAD, percutaneous, arterial access only, ie, Impella^® device
33991   Insert VAD, percutaneous, both arterial and venous access with transseptal puncture, ie, TandemHeart™ device
33992   Removal of VAD
33993   Repositioning of VAD
Follow these tips for proper coding:

• VADs are for use in patients with impaired LV function. The new aforementioned codes are for percutaneous VADs.
• Impella® device is via arterial access only, with a single catheter that forcefully removes blood from the LV via the distal portion of the catheter and discharges it into the proximal aorta.
• TandemHeart™ device has both venous and arterial access. The venous catheter is placed into the LA via a transseptal puncture and removes oxygenated blood from the left LA back to the TandemHeart™ device (external on patient), and then returns it into a second catheter, placed usually via the femoral artery.
• You may report 34812 Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral when an open arterial exposure is performed to accommodate the larger catheters used in percutaneous VADs.
• Routine closure of artery is not reported separately.
• Removal and repositioning codes can only be used when at a different encounter. If on the same date of service but a different encounter, append modifier 59 Distinct procedural service to either 33992 Removal of percutaneous ventricular assist device at separate and distinct session from insertion or 33993 Repositioning of percutaneous ventricular assist device with imaging guidance at separate and distinct session from insertion.
• If VAD is placed prophylactically for an intervention and removed at its conclusion, do not report 33992.
• Repositioning of a percutaneous VAD without imaging guidance is not a reportable procedure.
• If an existing VAD is removed and replaced with a new VAD, code this as a new device placement. Do not report 33992 because the removal is bundled into the new device placement code.

Electrophysiology Ablations

Electrophysiology ablation codes 93651 and 93652 are deleted. New abbreviated versions of the codes are:
93653   Comprehensive electrophysiologic (EP) evaluation with ablation of supraventricular tachycardia (SVT)
93654   Comprehensive EP evaluation with ablation of ventricular tachycardia
+93655 Additional ablation of discrete mechanism of arrhythmia distinct from the primary ablation treated
93656   Comprehensive EP evaluation with ablation of atrial fibrillation via pulmonary vein isolation
+93657 Additional ablation of left or right atrium for a-fib remaining after pulmonary isolation at same setting
Use these helpful tips for proper EP ablation coding:

• The five new ablation codes all include a diagnostic EP study at the time of ablation.
• Do not submit any combination of 93653, 93654, and 93656 together. If an additional mechanism is ablated, use add-on code +93655 or +93657.
• With ablation of SVT (93653), you may report mapping (+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) or +93613 Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure)), transseptal procedure (+93462 Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (List separately in addition to code for primary procedure)), and LV pacing/recording (+93622 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left ventricular pacing and recording (List separately in addition to code for primary procedure)), when performed.
• Ablation of VT (93654) includes 3-D mapping (93613) and LV pacing/recording (93622), when performed. You can report transseptal procedure (93462), when performed.
• Pulmonary vein isolation for a-fib (93656) includes the transseptal procedure (93462) and LA pacing/recording (+93621 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separately in addition to code for primary procedure)), when performed. You can report mapping (93609 or 93613) and LV pacing/recording, when performed.
• There is a “gray zone” regarding 93623; CPT® states this code may be reported with 93656, but National Correct Coding Initiative (NCCI) Version 19.0 states not to report 93623 with any of the new ablation codes.
• Add-on code +93655 may be reported with 93653, 93654, or 93656, when performed.
• Add-on code +93657 may be reported only with 93656, when performed.
• Some of the parentheticals may need updating. For example, a parenthetical note instructs you to use +93622 only with 93620, but the CPT® introductory section states +93622 may be added to 93653. Likewise, only 93620 may be used with 93621, per a parenthetical note following 93621.

Example: A patient presents with atrial fibrillation. A complete EP study is performed, followed by a transseptal puncture under intracardiac echocardiography (ICE) into the LA. A 3-D map is created, followed by ablations performed to achieve pulmonary vein isolation. After this was done, there was evidence of continued a-fib and a decision was made to perform additional right atrial ablations. The a-fib then ceased.
The correct coding in this case is:
93656
93662   Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation (List separately in addition to code for primary procedure)
93613
+93657
Note: Do not code for the EP study (93620) or transseptal procedure (93462); they are included in 93656.

Subcutaneous Implantable
Defibrillators (S-ICD)

This year, CPT® adds new Category III codes for S-ICD systems. Shortened descriptions are:
0319T   Insertion of complete system
0320T   Insertion of electrode only
0321T   Insertion of generator only
0322T   Removal of generator
0323T   Removal and replacement of generator
0324T   Removal of electrode
0325T   Repositioning of electrode and/or generator
0326T   EP evaluation (defibrillation threshold testing)
0327T   Interrogation of device
0328T   Programming of device with iterative adjustments
This is a newer type of defibrillator for treatment of arrhythmias that is totally implanted in the subcutaneous tissues, including the defibrillating lead.
To apply the above codes, follow these tips:

• The generator and one lead are placed subcutaneously. This allows for easier insertion over traditional transvenous insertion of electrode, and results in fewer potential complications, such as venous stenosis and infected leads within the heart because the lead is in the subcutaneous tissues.
• This system does not allow pacing, as in a conventional defibrillator.
• To report removal of an existing subcutaneous lead and generator plus replacement with a new system, report 0322T, 0324T, and 0319T.
• At generator end of life, report replacement with 0323T when the depleted generator is removed and a new generator is inserted.
• Use the repositioning code 0325T when performed repositioning of an electrode and/or generator occurs at a different encounter than at the original insertion.
• Defibrillation threshold testing (DFT testing) involves induction of arrhythmia and evaluation of sensing and pacing for arrhythmia termination, as well as reprogramming as necessary, and is reported with 0326T.
• Report 0327T and 0328T at a different encounter than at the original placement for interrogation or programming of S-ICD (this is not DFT testing).

Intracardiac Ischemia Monitoring Device (IMD)

Also new for 2013 are Category III codes (with our abbreviated descriptions) for IMD:
0302T   Insertion of complete system, or removal and replacement of both device and electrode
0303T   Insertion of electrode only, or removal and replacement of electrode
0304T   Insertion of device only, or removal and replacement of device
0305T   Programming of device with iterative adjustment
0306T   Interrogation of device
0307T   Removal of IMD system
IMD (AngelMed Guardian® system) consists of an electrode placed into the right ventricle and a device. It monitors electrocardiogram signals for acute ST elevation changes and warns the patient via vibratory and auditory alerts. This allows the patient to potentially seek earlier treatment of impending ischemic events.
Consider these tips when applying the above codes:

• The removal of an existing IMD system and replacement with a new system is reported by the single code, 0302T.
• Report codes 0305T and 0306T at a different encounter than at original placement for interrogation or programming of IMD.

Left Atrial Hemodynamic Monitor

Finally, you’ll find new Category III codes for left atrial hemodynamic monitor. Easier-to-follow abbreviated descriptions are:
0293T   Insertion of LA hemodynamic monitor, complete with module and pressure sensor lead
0294T   Insertion of pressure sensitive lead at time of insertion of pacing cardioverter-defibrillator
This system monitors LA pressures to identify changes in patients with heart failure to allow potential earlier treatment.
Tips to apply these codes correctly include:

• You may use the above codes alone, or when inserted into combination-type defibrillator devices.
• Transseptal code 93462 is bundled with these codes, as is ICE (93662).
• Use 0294T with 33230 Insertion of pacing cardioverter-defibrillator pulse generator only; with existing dual leads, 33231 Insertion of pacing cardioverter-defibrillator pulse generator only; with existing multiple lead, 33240 Insertion of pacing cardioverter-defibrillator pulse generator only; with existing single lead, 33262-33264 Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator …, and 33249 Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber.

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