Coding Electrophysiology Studies and Arrhythmia Ablation

Coding Electrophysiology Studies and Arrhythmia Ablation

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Electrophysiology studies and arrhythmia ablation can be tricky to report due to the number of bundled and add-on codes. Here’s a step-by-step approach to coding these medical procedures with confidence.

The Value of EP Studies

Electrophysiology (EP) studies are used to both diagnose and treat cardiac arrhythmias, typically during the same session. According to CPT® Assistant, “These tests are performed to evaluate whether a patient is at risk for certain heart events, evaluate the effectiveness of medication or determining therapy, evaluating for whether pacemakers or implantable cardioverter defibrillators are indicated.”

These studies look at the cardiac rhythm, which is induced by the heart’s electrical activity, and study cardiac arrhythmias. Cardiac arrhythmias can result from many things that damage the cardiac tissue and interrupt its electrical activity. The most common causes of this are congenital defects and conditions that cause scarring such as myocardial infarctions and high blood pressure.

5 Questions Solve Your EP Coding Dilemmas

If you find it difficult to assign CPT® codes to EP studies, ask yourself the following questions:

  1. Is this comprehensive?

The first thing to determine if this is a comprehensive EP study (93619-93620). To be considered “complete,” five things must be done:

  • Right Atrial Pacing (93610 Intra-atrial pacing)
  • Right Atrial Recording (93602 Intra-atrial recording)
  • Right Ventricular Pacing (93612 Intraventricular pacing)
  • Right Ventricular Recording (93603 Right ventricular recording)
  • Bundle of His Recording (93600 Bundle of His recording)

If the documentation does not show all five of these components, the study is not considered comprehensive. Report each component individually, rather than report the single code for a comprehensive exam.

  1. Was arrhythmia induction attempted?

Arrhythmia induction can be done by performing pacing at different rates or by programmed simulation. Programmed simulation is done by introducing timed electrical impulses. Arrhythmia induction, alone, is reported using 93618 Induction of arrhythmia by electrical pacing.

Report a comprehensive study with attempted arrhythmia induction using 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.

Report a comprehensive study performed without an attempt of arrhythmia induction using 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.

Note that the CPT® code descriptor for 93620 states, “with induction or attempted induction of arrhythmia.” A common coding misconception is that if the induction fails, then report 93619. The attempt, whether successful or unsuccessful, is all that is needed to assign 93620, instead of 93619.

  1. Were any add-ons performed?

Report intravenous (IV) drug infusion to induce arrhythmia using +93623 Programmed stimulation and pacing after intravenous drug infusion (List separately in addition to code for primary procedure). Use 93623 to report induced ablation for diagnostic measures, not for confirmation after ablation, and with comprehensive EP studies, only.

Report left ventricular pacing and recording using +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); and report left atrial pacing and recording from coronary sinus or left atrium using +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). Report these codes with comprehensive EP studies, only.

Mapping is done to view the arrhythmias and identify the origin to determine where to ablate. Mapping can be done in either 2D (+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 3D (+93613 Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure)). If both types are used, report only the more comprehensive 3D mapping.

Intracardiac echocardiography guidance (+93662 Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation (List separately in addition to code for primary procedure)), typically referred to as ICE guidance, also may be performed. This is ultrasound-type guidance to view the endocardium from inside the heart. It allows the technician to identify landmarks, ensure locations for ablation, and evaluate intracardiac structures.

If add-ons are performed and are required to be reported in addition to a comprehensive EP study code, but not all of the requirements are met for reporting a comprehensive EP study code, then report a comprehensive study code with modifier 52 Reduced services, plus the applicable add-on codes.

  1. Was ablation performed?

Ablation coding depends on the type of arrhythmia treated. There are three types of arrhythmias with ablation codes:

Supraventricular tachycardia ablation (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 (when necessary), and His bundle recording (when necessary) with intracardiac catheter ablation of arrhythmogenic focus; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry)

Supraventricular tachycardia (SVT) is a rapid heart rhythm involving areas above the ventricles. There are many types of SVT. The two most common are:

Atrioventricular reentrant tachycardia (AVRT) – This condition is provoked by an accessory pathway for an electrical impulse from the ventricle to the atria. In normal sinus rhythm, an electrical impulse is set off from the sinoatrial (SA) node. This electrical impulse then travels to both atria and causes them to contract. There is a small delay before the impulse reaches the atrioventricular (AV) node to allow blood flow. From the AV node, the impulse then goes to the bundle of His and then to the ventricles to allow them to contract. Finally, the impulse reaches the Purkinje fibers, where the impulse ends and the heart waits for another impulse to generate from the SA node. Patients with AVRT have an accessory pathway located in the ventricle that allows the impulse signal to re-enter the atrium, which causes contracting that shouldn’t happen until a new signal comes from the SA node. This causes the heart to be tachycardic.

Atrioventricular nodal reentrant tachycardia (AVNRT) – This is similar to AVRT, but patients with AVNRT have an accessory pathway at or near the AV node, which allows the impulse to re-enter from the AV node to the atrium, causing tachycardia.

Ventricular tachycardia ablation (93654 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 (when necessary), and His bundle recording (when necessary) with intracardiac catheter ablation of arrhythmogenic focus; 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)

Ventricular tachycardia (VT) is tachycardia confined to the ventricles of the heart and is defined when three or more consecutive premature ventricular contractions are produced. Ventricle cells can produce an electrical impulse. Under normal conditions, these cells never get a chance to initiate a heartbeat because the SA node fires at a quicker rate. In focal VT, the ventricle cells abnormally fire quicker than that of the SA node. VT can also result from these impulses re-entering the impulse flow, such as atrioventricular re-entrant tachycardia, but instead coming from the ventricle. The surgeon will ablate the areas of concern in the ventricles for ventricular ablation.

Atrial fibrillation (93656 Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia including left or right atrial pacing/recording when necessary, right ventricular pacing/recording when necessary, and His bundle recording when necessary with intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation)

Atrial fibrillation (AFib) is a rapid heart rhythm caused by a defect in the tissue at the entry way of the pulmonary veins, at the left atrium. This causes the atria to fibrillate rapidly instead of contracting rhythmically. Ablation for AFib is performed by first isolating the pulmonary veins to locate the point of origin. Then, the provider will perform a transseptal puncture, if needed, to access the left atrium to ablate the locations on the pulmonary veins, either by radiofrequency or cryo-energy ablation. Typically, pulmonary vein isolation is performed again to confirm the ablation was a success or if additional ablation is needed. Report +93657 Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List separately in addition to code for primary procedure) with 93656 if successful pulmonary vein isolation is achieved, attempts at re-induction of AFib identify an additional left or right atrial focus of AFib, and further ablation of the new focus is performed. Report 93656 only once per operative session.

  1. Was another distinct ablation also performed?

Report +93655 Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia (List separately in addition to code for primary procedure) when a distinct arrhythmia is ablated in addition to a primary ablation. Primary ablation does not mean the first item ablated, but rather indicates the clinical arrhythmia for which the patient was treated.

For example, a patient present with AFib and undergoes a comprehensive EP study with induced arrythmia. The “first” arrythmia to be induced is atrial flutter. The provider ablates atrial flutter and induces arrhythmia again. This time, AFib is induced. The physician then isolates the pulmonary veins and ablates the AFib. This scenario is reported using 93656 for the primary AFib ablation and +93655 for the atrial flutter.

Remember: You may report +93655 with AFib ablation (93656) for a distinct non-AFib of ablation; or you may report +93655 with SVT ablation (93653) or VT ablation (93654) when there is ablation of an additional area of SVT or VT mechanism, or other distinct arrhythmia mechanism. You may report more than one unit of +93655 during the same operative session, if applicable.

Study the code descriptors to see what add-on procedures are included with each type of ablation. For example, a left ventricular puncture has an add-on code (+93462 Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (List separately in addition to code for primary procedure)), which can be reported in addition to SVT or VT ablation, but is included in AFib ablation. AFib ablation also includes left atrial pacing and recording from coronary sinus or left atrium. Finally, remember that a comprehensive EP study is included with all ablation codes.


Hayley Sutton, CPC, CCC, CCS, is an inpatient coder for Sentara Martha Jefferson Hospital. She previously worked as an outpatient coder, coding same-day surgeries. Sutton also has experience in gastroenterology and cardiology coding. She is in the process of obtaining her bachelor’s degree in health information management. Sutton is a member of the Aurora, Ill., local chapter.

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