If you’re not coding repeat ablations the right way, you’re leaving money on the table. Considering that it’s not at all uncommon for patients to require additional ablation procedures, you need to know the correct coding rules to capture the reimbursement your cardiology practice deserves.
Problem: Healthcare organizations and physicians are busier than ever, and their volume of cardiology patients has only increased while their reimbursements have decreased, according to Terry Fletcher, CPC, CCC, CEMC in CPT Coding for EP: Pacemakers, Ablations, ICDs & More. You need to be as proactive as possible to ensure that you’re getting the reimbursement you’ve earned for electrophysiology (EP) services, ablations, pacemakers, and implantable cardioverter defibrillators (ICDs).
Ponder the Cause Behind Ablation Re-Do
Consider this: Patients with a larger pulmonary vein size are likely at a greater risk for needing repeat ablation procedures, according to “Clinical and Anatomic Predictors of Need for Repeat Atrial Fibrillation Ablation” in the World Journal of Cardiology. In the study of 331 patients, 142 (43 percent) patients underwent repeat ablations.
Interestingly, the patients who had a larger pulmonary vein size determined by pre-procedure cardiac magnetic resonance imaging had an increased likelihood of requiring an ablation re-do, the researchers found. And each millimeter increase in pulmonary vein diameter linked to an approximately 5- to 10-percent increased risk of needing repeat procedures.
If you encounter a situation where a patient underwent a repeat ablation for atrial fibrillation, you have two coding options, according to the “2018 FAQ: EP Coding and Reimbursement, Physicians and Facilities” by Biosense Webster.
1. Stay Conventional with 93656
Try this: Your first option is to report the afib treatment using CPT® code 93656, Biosense instructed. The usual bundling edits will apply for any additional services like transseptal puncture. But you would report 3-D mapping (93613) or intracardiac echo (93662-26) separately.
For physician billing, 93656 has 32.68 Relative Value Units (RVUs) and a calendar year (CY) 2018 national payment rate of $1,176.15, according to “2018 Coding and Reimbursement for Cardiac Surgical Ablation and Left Atrial Appendage Management” by AtriCure.
The 93656 code definition is: “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.”
Reasoning: You would report 93656 for a second ablation, because it’s not uncommon that some patients will need more than one afib treatment, Biosense explained. The CPT section notes state that 93656 “is a primary code for reporting treatment of atrial fibrillation by ablation to achieve complete pulmonary vein electrical isolation.”
This means that, although code 93656 includes ablation around all four pulmonary veins, the intent is to achieve isolation, and the code doesn’t require repeat ablation on all four sites if one of the pulmonary veins has reconnected.
2. Take a Different Coding Approach with 93653
Another way: Your second option is to report 93653 for an EP study with atrial ablation. You could use this code if the pulmonary vein isolation is complete from the initial treatment and the repeat intervention is specifically limited to additional sites, such as the roofline or isthmus, Biosense stated.
CPT code 93653 has an RVU of 24.33 and a CY 2018 national payment rate of $875.64, AtriCure reported.
The definition for 93653 is: “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), 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 connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry.”
Why? Although there are specific codes for afib treatment, there is nothing in 93653’s definition that prevents you from reporting it when the procedure is not pulmonary vein isolation, Biosense stated. In fact, the code definition references multiple different possible sites. But you should keep an eye on these claims, because third-party payer criteria and other edits may question a claim with an afib diagnosis where you didn’t report 93656.
You would then separately report as necessary the transseptal access (93462), intracardiac echo guidance (93662-26), 3-D mapping (93613), and/or left atrial pacing/recording (93621-26).
Key takeaway: Correct ablation CPT coding, pacemaker CPT coding, and coding for EP studies and ICDs is more crucial than ever before, Fletcher stresses. So make sure you’re taking the initiative in your cardiology coding practices to optimize your reimbursement and prevent denials.
