When performing a multiple-catheter electrophysiology (EP) study including left atrial or left ventricular recording, CPT coding principles and the national Correct Coding Initiative (CCI) specify that only one complete study should be billed. However, several authoritative sources offer conflicting coding advice.
As a result, CPT 2002 is expected to revise how these procedures are coded and billed. In late April, representatives from the American College of Cardiology (ACC) and the North American Society of Pacing and Electrophysiology (NASPE) met with the AMAs Relative Value Update Committee to address the proposed changes and determine how the revamped codes should be valued.
Any changes (which have yet to be officially announced) would not take effect at least until Jan. 1, 2002. Until then, the billing of EP studies should be governed by the wording of the code descriptors in CPT and bundling guidelines in the CCI unless otherwise indicated (in writing) by the carrier.
CPT 2001 lists four EP study codes:
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 [this code is to be used when 93600 is combined with 93602, 93603, 93610, 93612); 12.25 relative value units (RVUs);
93620 with induction or attempted induction of arrhythmia (this code is to be used when 93618 is combined with 93619); 19.41 RVUs;
93621 with left atrial recordings from coronary sinus or left atrium, with or without pacing, with induction or attempted induction of arrhythmia; 21.20 RVUs; and
93622 with left ventricular recordings, with or without pacing, with induction or attempted induction of arrhythmia; 21.32 RVUs.
Note: The RVUs associated with each code above represent the facility fee. Modifier -26 (professional component) should be attached to any of these procedures when performed in the hospital.
Billing Issues
These codes are sequential, with the second code building on the first, and so on (with one important exception: See Note below). For example, says Rebecca Sanzone, CPC, billing manager with Mid-Atlantic Cardiovascular Associates, a 47-cardiologist practice in Baltimore, 93620 includes all the elements of 93619 but also includes induction or attempted induction of arrhythmia. Similarly, 93621 includes 93620 but adds left atrial recordings from the coronary sinus or left atrium.
Note: Code 93622, which includes left ventricular recordings, does not also include left atrial recordings, and therefore does not follow in sequence from 93621. However, like 93621, it includes 93620.
Several factors complicate the billing of EP studies. First, the additional reimbursement for 93621 and 93622 (1.79 and 1.91 RVUs, respectively) does not adequately compensate for the additional work of obtaining recordings from the coronary sinus/left atrium or left ventricle. Second, both 93621 and 93622 are designated by CPT 2001 as modifier -51 (multiple procedures) exempt a status usually reserved for list separately in addition to, or add-on, codes.
Perhaps as a result, many authoritative coding guides instruct providers to bill more than one code if either atrial or ventricular recordings are performed. For example, the August 1998 CPT Assistant (published by the AMA) issued a clarification on billing 93620, 93621 and 93622:
Code 93620 identifies a number of services including a comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, bundle of His recording, and induction or attempted induction of arrhythmia. If left atrial and/or ventricular recordings are also performed, in addition to inducing or attempting to induce arrhythmia for the right atrium/ventricle, then it would be appropriate ... to report codes to describe the placement of additional catheter(s) in appropriate cardiac chamber(s) for further EP study(ies) of the left atrium and/or left ventricle with 93621 and/or 93622. Therefore, 93621 and/or 93622 may be used to identify the left atrium/ventricle recordings, and code 93620 may be used to identify the right atrial and ventricular pacing and recordings as well as induction or attempted induction of arrhythmia.
NASPEs CPT Coding Guide for Electrophysiology and Pacing Procedures 2000-2001 (commonly referred to as the Blue Book) cites the CPT Assistant article to bolster its case for billing 93620 and 93621 and/or 93622 during the same session, and notes that the ACCs Practical Reporting of Cardiovascular Services and Procedures Coding Guide, published in 2000, also agrees with the AMA position.
According to CPT, however, the right atrial and ventricular recordings are already included in 93621 and 93622. The introduction to CPT states, Some of the procedures in CPT are not printed in their entirety but refer to a common portion of the procedure listed in a preceding entry. This is evident when an entry is followed by one or more indentations. This is done in an effort to conserve space.
The following example is cited:
25100 arthrotomy, wrist joint; with biopsy
25105 with synovectomy
CPT then notes, the common part of code 25100 (that part before the semicolon) should be considered part of code 25105. Therefore, the full procedure represented by code 25105 should read:
25105 arthrotomy, wrist joint; with synovectomy.
The relationship between 25100 and 25105 in this example precisely mirrors that of 93619-93622. In fact, Medicodes Coding Illustrated Cardiovascular and Respiratory, when providing the code descriptors for 93620 and 93622, includes the common portion of 93619 in all three codes.
Follow CCI Edits
CCI has long bundled component code 93620 to comprehensive codes 93621 and 93622. Until January 2001, however, the edit included a 1 indicator, meaning the second code could be reported with modifier -59 (distinct procedural service) appended (as long as the criteria for using modifier -59 for example, two procedures performed at different times on the same day were met). But in CCI version 7.0, the edit was given a 0 indicator, which means the edit can no longer be bypassed.
NASPE is now (correctly) instructing its members not to bill 93620 and 93621 (or 93622) together to local Medicare carriers. However, the association is still advising that these codes may be billed together to private carriers who are not obliged to adhere to CCI edits.
Doing so, however, may run afoul of compliance programs that guide physicians to follow the same billing policies for all payers unless instructed in writing to bill differently by an individual carrier, notes Kathleen Mueller, RN, CPC, CCS-P, an independent coding and reimbursement specialist in Lenzburg, Ill.
The ACC, while recognizing that the 0 indicator makes billing 93620 in addition to 93621 (or 93622) more difficult, has issued a reinterpretation of CCI that it says justifies continued billing of the procedures.
According to an article in the April 1, 2001, issue of ACC News, Version 7.0 of the CCI does not bundle codes 93621 and 93622 with comprehensive code 93620 [i.e., if the physician reports 93620 as the primary procedure, he or she may report 93621 or 93622 separately]. However, when codes 93621 or 93622 are reported as the primary or . . . comprehensive procedure, code 93620 does have the numerical indicator 0 beside it and is consequently considered to be bundled with codes 93621 and 93622.
But there is no basis for this reversal of comprehensive and component code status. CCI edits are listed only in one direction, says Susan Callaway, CPC,CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. You cant look up a component code 93620 and see the edit with 93621 but that doesnt mean the edits dont exist.
Furthermore, Callaway continues, When a pair of codes is bundled, one code always is comprehensive and the other always is a component. Once the CCI determines the status of the codes involved, neither physicians nor coders can arbitrarily alter that status. She adds that changing the order of the codes on the HCFA 1500 claim form doesnt affect the carriers software, which incorporates the CCI edits to determine the status of the codes being billed.
Although most local Medicare carriers do not address this issue in published local medical review policies, those that do either suggest or state outright that 93620 and 93621/93622 should not be billed together.
For instance, Empire Medicare Services, the carrier in New Jersey and parts of New York, specifies, The range of codes represents a sequential progression of services, where each service builds upon previous services. Therefore, Correct Coding edits should be referred to to report the code that represents the most comprehensive description of the service rendered.
Alabama Blue Cross Blue Shield, that states local Medicare carrier, instructs providers more plainly:
CPT code 93621 (and 93622) includes the components of CPT code 93620, but additionally this code includes left atrial recording from the coronary sinus or left atrium with or without pacing. If procedure code 93621 is billed in conjunction with procedure code 93620, reimbursement should only be allowed for CPT code 93621, since 93620 is included in 93621. The local medical review policy goes on to state that if either 93621 or 93622 is billed in conjunction with 93620, the latter will be denied because Medicare payment for this service was included as part of another service.
Same-session Left Atrial and Ventricular Recordings Although both 93621 and 93622 include 93620, the two left-chamber codes do not include each other because the study of the left ventricle (infrequently performed, in any event) does not necessarily require a corresponding left atrial or coronary sinus study. Similarly, left atrial or coronary sinus recordings are usually performed without an investigation of the left ventricle. Therefore, when recordings of both left chambers are obtained, a separate service should be billed.
This does not mean, however, that 93622 should be billed with 93621: Both codes include the base procedure represented by 93619/93620. Billing 93621 and 93622 would represent obtaining payment for the same service (the right chamber and bundle of His recordings, for instance) twice. These codes, therefore, should not be billed together unless a carrier specifically instructs its providers to do so.
According to ACCs Guide to CPT 2001: Practical Reporting of Cardiovascular Services and Procedures, If left atrial and left ventricular recordings are both required, 93621 can be used in conjunction with 93607 [left ventricular recording] to separately indicate the need for left ventricular recording.
Note: Because 93607 is part of a series of codes (preceding 93619) that are included in comprehensive EP studies, appending modifier -59 to 93607 may be necessary to alert the carrier that the component code was not part of the EP study and was performed on a separate site (i.e., the left ventricle).
Check With Your Carrier
Individual carriers may have their own system for reporting left atrial/coronary sinus and left ventricular recordings performed during the same session, some of which include physician review. For example, Alabama Medicare (Blue Cross Blue Shield) tells carriers, If both 93621 and 93622 are billed on the same patient on the same day, medical record documentation must be attached using billing indicator U2 for physician review.
Because policies on this issue (and the larger issue of 93620/93621/93622) vary widely, carriers should be contacted ahead of time for the required billing approach. Meanwhile, NASPE and ACC expect that CPT 2002 will clarify the problem once and for all by changing 93621 and 93622 into add-on codes that could be used only in addition to 93620.
Although reimbursement for such add-on procedures is bound to be less than that currently assigned to 93621 and 93622, it is likely to be considerably more than the 1.79 and 1.91 RVUs now available to electrophysiologists who perform left and right chamber EP studies and bill them correctly using only one code.
