Cardiology Coding Alert

When the physician combines multiple services in one session, check these codes first.

Many coders are responding to the AMA's creation of five new electrophysiology codes with a resounding "It's about time!" But there's also concern that the way the new codes bundle services will lead to revenue loss.

Action plan: You can't control the RVUs Medicare will assign, but you can submit clean claims to reduce time-consuming, costly denials. Study the new codes so you're ready to apply them for services on and after Jan. 1, 2013.

Study Definitions of Deleted and Added Codes

CPT® 2013 will delete the following ablation codes, says Julie Graham, BA, CPC, cardiology coder and compliance specialist for Concentra in Texas:

• 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
• 93652, ... for treatment of ventricular tachycardia.

But deletions aren't the only news. CPT® 2013, effective Jan. 1, also will add five new electrophysiology (EP) codes, Graham says:

• 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, His recording with intracardiac catheter ablation of arrhythmogenic focus; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry
• 93654, ... 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
• +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)
• 93656, Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with atrial recording and pacing, when possible, right ventricular pacing and recording, His bundle recording with intracardiac catheter ablation of arrhythmogenic focus, with treatment of atrial fibrillation by ablation by pulmonary vein isolation
• +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).

Primary Codes Are Like Combo Platters

Three of the new codes (93653, 93654, and 93656) each include comprehensive EP evaluation, ablation, and other services. In other words, you'll report a single code to describe multiple services.

Example: The electrophysiologist performs a comprehensive EP evaluation by inserting multiple electrode catheters, inducing arrhythmia, and performing right atrial (RA) pacing and recording, right ventricular (RV) pacing and recording, and His bundle recording. He performs left ventricular (LV) pacing and recording, and 3D mapping, as well. He then performs ablation to treat ventricular tachycardia.

In 2012, you report:

• Evaluation 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)
• LV pacing and recording using +93622 (... with left ventricular pacing and recording [List separately in addition to code for primary procedure])
• 3D mapping using +93613 (Intracardiac electrophysiologic 3-dimensional mapping [List separately in addition to code for primary procedure])
• Ablation using 93652 (Intracardiac catheter ablation of arrhythmogenic focus; for treatment of ventricular tachycardia).

In 2013, all of the services will be covered under 93654.

Caution: Keep an eye on the 2013 fee schedule. Typically, when services that are billed together most of the time become bundled into a single code, physicians see a loss in reimbursement, Graham says. So "bundling the EP evaluations with ablations may really hurt from a monetary standpoint given bundling trend history." In very rare cases, reimbursement increases, she notes. Bottom line: Compare your 2012 and 2013 reimbursement for these services once fee information is released.

Check Dx and Technique Before Coding

When reviewing the new code definitions, be sure to watch for reference to supraventricular arrhythmia, ventricular arrhythmia, and atrial fibrillation, as well as reference to technique, says Graham.

As you can see in the definitions, 93653 refers to treatment of supraventricular tachycardia, and 93654 includes treatment of ventricular tachycardia or focus of ventricular ectopy.

Technique tip: Code 93656 requires "treatment of atrial fibrillation by ablation by pulmonary vein isolation." In short, this treatment involves using a specialized catheter to apply energy (direct current, freezing, etc.) that creates scarring around where the pulmonary veins connect to the left atrium. The goal is to block irregular impulses. The procedure typically involves a transseptal puncture, says Christina Neighbors, MA, CPC, CCC, ACS-CA, charge capture/reconciliation specialist and coder at St. Joseph Heart & Vascular Center in Tacoma, Wash.

Remember: When all components of the comprehensive EP procedure code definition are not documented, consider whether appending modifier 52 (Reduced services) to the code would be appropriate.

A-fib tip: When a patient is having an A-fib ablation, the physician often will not put a diagnostic EP catheter directly in the RA. Catheters placed within the atrium (right or left) could put the patient into a dangerous arrhythmia.

Many experts advise that a complete EP study may include RA pacing and recording from the cor sinus along with His and RV pacing and recording.

Watch for the term "antegrade" pacing and recording for atrial (RA or LA) services, or "retrograde" pacing and recording for ventricular (RV or LV), says Neighbors.

Apply Add-On Options Appropriately

The two new add-on codes offered by CPT® 2013 both describe additional ablation services, but you'll use them under different circumstances.

+93657: The previous section introduced 93656 for A-fib treatment by pulmonary vein isolation. If the physician then, at the same session, performs additional ablation of sites distinct from the primary ablation site to treat A-fib, you'll report new code +93657 in addition to 93656. As an example, suppose "pulmonary vein isolation is successful, re-induction of A-fib is identified, and an additional right atrial focus A-fib rhythm arises, requiring an additional ablation," says Neighbors.

+93655: Another new add-on code, +93655, is more flexible in its application than +93657 is. "Code 93655 is listed in conjunction with 93653 when repeat ablation is for treatment of an additional supraventricular tachycardia mechanism and with 93654 when the repeat ablation is for treatment of an additional ventricular tachycardia mechanism. Code 93655 may be reported with 93656 when an additional non-atrial fibrillation tachycardia is separately diagnosed after pulmonary vein isolation," according to the 2013 guidelines.

Final Tip: Watch for Improper Denials

As payers adjust to the new codes, you may find that they deny correctly billed codes, Graham warns. "This could be something we encounter with the new EP codes bundling comprehensive studies and ablations."

Keep an eye out for denials of new codes or new codes paired with other codes so you can appeal. Be sure to inform the payer of why your claim is accurate based on code definitions and guidelines.

Also see: "93653-+93657 Breakdown Lets You Master New Codes in a Snap" on page 91 summarizes what's included in the new codes, available add-on codes, and forbidden code combinations.