Closing the Hole: Patent Foramen Ovale Surgery Subject to Bundling Rules

As technology and research advance rapidly for  percutaneous procedures of the heart, coding updates and changes will follow.

By David Zielske, MD, CPC-H, CCS, RCC

The most common congenital heart defects are the patent foramen ovale and atrial septal defects. These heart defects are open communications between the right and left atria and can vary in size and presentation of symptoms.

During embryologic development, oxygenated blood flows to the fetus from the mother via the umbilical artery. Since the fetal lungs are fluid-filled, the oxygenated blood bypasses the lungs and proceeds from the right side of the heart (right atrium) to the left side of the heart (left atrium) via the foramen ovale. The foramen ovale closes off completely in 76 percent of people shortly after birth, no longer allowing unoxygenated blood to pass from the right side of the heart to the left. If this “hole” in the interatrial septum remains open after birth, it is referred to as a “patent” foramen ovale (PFO).  Surprisingly, this occurs in 24 percent of the population. Fortunately, most individuals with a PFO have small openings that are asymptomatic throughout life. Unfortunately, these PFOs may result in serious complications under certain circumstances.

Complications

The lungs oxygenate blood and filter the venous blood return, helping to trap small blood clots that may form in the peripheral veins. Although large blood clots that reach the lungs (pulmonary emboli) may cause serious problems, smaller blood clots occur quite often in healthy individuals and are never recognized. Between the filtering/trapping function of our lungs and certain blood clot dissolvers, the smaller blood clots resolve quickly without complication.

Problems may occur, however, when a small blood clot passes through a PFO from the right atrium to the left-sided circulation instead of its usual path through the lung. If the small blood clot passes through the right atrium at the same time as an unusual increase in right atrial pressure above left atrial pressure as occurs during a Valsalva maneuver (e.g., bearing down, coughing), the blood clot can pass into the left-sided circulation, proceed through the left ventricle, out the aorta, and then travel to wherever the bloodstream takes it. This clot may then occlude some or all of the blood flow to the affected artery, resulting in stroke (if the artery is to the brain), end organ infarct (if the artery is to the kidney, spleen, liver or bowel), or acute extremity ischemia (if the artery is to the arm or leg). When this occurs, immediate intervention is required to prevent permanent damage and death of tissue. This can be performed via open or percutaneous techniques, including thrombectomy, embolectomy or thrombolysis.

Previously, treatment for PFO required median sternotomy and open cardiac surgical technique with insertion of a patch to close the hole. Percutaneous techniques have been developed, utilizing a “double umbrella device” that, when released, fans out within both the left atrium and right atrium. After partial deployment in the left atrium, the device is snugged up against the hole and then further released in the right atrial side for completion of the procedure.

Coders will see separate approaches to both the right and left heart. The first catheter will size the defect and then the occlusion device is loaded in for deployment. Over time, this device is endothelialized and completely covers and closes the PFO. Concerns of current devices include possible metal fatigue and fracture over time. Second and third generation devices have been developed and are currently in research. Some of these devices include intrashunt occluders deployed within the interatrial wall, biodegradable devices which completely resorb over time after endothialization, percutaneous suture mediated closure devices, and radiofrequency sealing procedures which would not require an implant at all.

Regardless of the technique utilized, coding these procedures is straightforward. There is a single CPT® code (93580) for a PFO closure. This code bundles the performance of a right heart catheterization, left heart catheterization, right atrial angiography, and right ventricular angiography (codes 93501, 93529-93533, 93539, 93543 and 93555), and these codes should not be reported at the same time as the intervention.

Code 93580 also is the indicated choice for percutaneous closure procedures of larger atrial septal defects (ASD) or for closure of a fenestration identified after a Fontan congenital reconstruction. Intracardiac echocardiography (ICE, 93662) and transesophageal echocardiography (TEE, 93318) guidance are separately reportable with this procedure. They are utilized to not only determine size and guide accurate placement of the device, but also to test the efficacy of the device placement and document occlusion of the previous right to left shunt as demonstrated by a normal “bubble study.”

Some of the rules to follow include use of code 93580 for ASD closure, PFO closure and Fontan fenestration closure procedures. Congenital diagnostic heart catheterization procedures are bundled into the PFO closure code 93580 when performed at the time of the PFO closure. Utilization of echocardiography (TEE, 93318 or ICE, 93662) is quite common during PFO closure procedures and these codes are separately reportable.

Currently available FDA-approved devices include the CardioSEAL® Septal Occluder and the Amplatzer® PFO Septal Occluder, as well as the Amplatzer Multi-Fenestrated Septal Occluder Cribriform device. Devices pending FDA approval include the PFO Star® device, the Helex® device, and the Proximare PFO Occluder.®

Most PFOs are unrecognized until they present with critical ischemia (e.g., stroke, visceral infarct, leg ischemia) due to paradoxical embolus. Do not confuse this procedure with the occlusion of a septal defect within a ventricular location (VSD), which is coded with 93581, 0166T or 0167T depending on the technique utilized.

Examples: 1) A 32-year-old non-smoking female with history of migraines presents to the emergency room with symptoms of stroke. Carotid/cerebral angiography shows a small MCA embolus, which is successfully treated with percutaneous catheter directed thrombolytic technique. Further workup with TEE shows a PFO with right to left shunting. These diagnostic and interventional procedures are separately reported and coded. The next day, via a transfemoral venous approach, a catheter is placed in the right atrium, right ventricle, and left atrium, where pressures and angiography are performed (bundled with closure device placement). Pulmonary artery pressures are normal. ICE confirming a PFO with aneurysm is utilized for sizing and location of the PFO (93662) and follow up bubble study at the end of the procedure. A sheath is then advanced across the PFO, and the closure device is partially deployed in the left atrium and pulled back to snug the device to the atrial septal wall. The right atrial side of the device is then deployed (93580). Bubble study with ICE demonstrates complete occlusion of the PFO. Patient is discharged later in the day.

2) A 3-year-old male presents with congenital heart disease, pulmonary artery stenoses and Fontan fenestration. Via right femoral vein approach, a catheter is advanced into the right side of the heart via the Fontan fenestration with right atrial pressures and imaging obtained. Pulmonary angiography is performed (93541, 93556) showing recurrent stenosis in a left upper lobe and left lower lobe pulmonary arterial branch. Each of these is separately dilated with a 4 mm followed by a 5 mm balloon (92997, 92998).  Excellent results are obtained. Measurements of the Fontan fenestration are made with ICE (93662) and an appropriately sized Amplatzer® PFO Septal Occluder is chosen and deployed, successfully occluding the fenestration (93580). This is confirmed with follow-up bubble study (part of 93662 above).

If you search the internet, you will find that each third party payer has a policy on how to get reimbursed for this service, so be sure to check your local policy. If your provider is engaged in clinical trials, beware that any patient care covered under the grant for the trial should not be billed to the patient. In this case, you should set up a dummy code in your billing system to store data that will not cause a bill to drop.

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