Cardiology Coding Alert

When an electrophysiological evaluation reveals an accessory pathway, the physician may decide to perform an ablation either during or after the session. Code 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) is used to report the ablation, which typically includes placing catheters in the right atrium, the region of the His bundle, the coronary sinus and the right ventricle.
 
Although a fifth catheter is usually placed retrograde across the aortic valve to map and ablate the accessory pathway, the surgeon may have to take a transseptal approach instead and puncture the atrial wall from the right side to get the catheter to the left side where it is needed. Reimbursement for the additional work and risk involved in performing a transseptal puncture can be difficult to obtain, mainly because CPT does not have a code for this procedure.
Avoid Double-Dipping
The North American Society of Pacing and Electrophysiology (NASPE) recommends that physicians bill both 93651 and 93527 (Combined right heart catheterization and transseptal left heart catheterization through intact septum [with or without retrograde left heart catheterization]) when a transseptal approach is chosen over a retrograde aortic approach. NASPE also instructs physicians who bill Medicare carriers to append modifier -59 (Distinct procedural service) to 93651.
 
Note: The same applies to 93652 (Intracardiac catheter ablation of arrhythmogenic focus; for treatment of ventricular tachycardia): NASPE recommends reporting both 93652 and 93527 when a transseptal approach is used.
 
Unfortunately, Medicare and private carriers may accuse a physician who codes the session this way of double-dipping or fraud, says Nikki Vendegna, CPC, a cardiology coding and reimbursement specialist in Overland Park, Kan. "It is inappropriate to bill 93527 in addition to 93651, because a cardiac catheterization has not been performed," she says. "Although the catheters used to ablate the pathway may resemble what is performed in a combined right and left heart cath, the placement of these catheters is part of 93651, so to go ahead and bill 93527 as well is double-dipping and, therefore, inappropriate."
 
Vendegna also points out that the catheters are not placed for the same reason in an ablation as they are in a cardiac catheterization. "Heart caths are performed to take measurements and look for specific types of heart disease, such as coronary artery disease and cardiomyopathy. That is not the purpose of an ablation, which is performed to destroy an electrical pathway in the heart." There may not be a diagnosis to support a heart cath even if pressures are taken, she says.
 
Note: When the ablation is performed following an electrophysiological study during the same session or in different [...]