Changes Coming for 2013 CPT Codes

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End page: 
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Author(s): 

Jim Collins, CPC, CCC, President, CardiologyCoder.Com, Inc.

The 2013 CPT codes have been finalized; brace for an overhaul in the way you report ablation procedures effective January 1st. Gone are the codes we’ve used for eons to report all SVT and VT ablations — in their place are monolithic beasts which must be conquered to secure full reimbursement for future ablations.

Code 93651 is currently used to report all supraventricular tachycardia ablations. This service is typically reported in addition to a diagnostic EP study and mapping of some sort. Left atrial pacing and recording (93621), Isuprel infusion (93623), and intracardiac echo (93662) are occasionally reported at the time of an SVT ablation.

The biggest problem with code 93651 is that it encompasses all forms of SVT ablation without providing additional credit for complex ablations like atrial fibrillation ablation, arrhythmias originating from multiple focal points, or procedures requiring the interruption of multiple pathways.

CPT 2013 partially fixes this problem by including five new codes that can be used to report ablation procedures in a way that permits more precise reporting of complex procedures. However, the new codes include a lengthy “honey do” list of procedural components that must be performed and documented in order to secure whatever premium payers decide to grant ablation procedures. If we fail to hit every checkbox on the list, it will be necessary to attach the reduced service modifier (52) to the new ablation codes and risk substantial payment reduction.

From the mile-high view, you’ll see four codes available to report basic ablation procedures in 2013. The AV node ablation procedure code (93650) is the same as it ever was — no changes here. However, code 93656 stands out as the new atrial fibrillation ablation code. This is an “all in one” code intended to encompass the full scope of the procedure — kind of. But to report it, you must perform and document each of the listed procedural components. Here they are:

  • Multiple transseptal catheterizations
  • Induction or attempted induction of an arrhythmia
  • Right and left atrial pacing (when possible)
  • Right and left atrial recording (when possible)
  • Right ventricular pacing
  • Right ventricular recording
  • His bundle recording
  • Pulmonary vein isolation

If any of these procedural components are missing from your documentation, it will be necessary to report 93656-52 — the dreaded 52 modifier forces the claim to be manually priced by payers (long payment delay and reduced compensation). 

On the bright side, code 93656 does not always have to be reported alone. CPT 2013 introduces an add-on service code that can be used when additional ablations are required after the pulmonary vein isolation portion of the procedure. Code 93657 is used to report “additional linear or focal intracardiac catheter ablation of left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation.” Better yet, CPT 2013 does not restrict us from reporting this add-on code just one time. Therefore, you could rack up some serious RVUs by creating more complete ablative lesion sets during the initial procedure. 

Code 93655 can also be reported after an AF ablation for cases in which the AF ablation unmasks another SVT. This code is to be used for “ablation of discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism.” Like 93657, code 93655 is an “add-on” code that can be reported multiple times.

While the pulmonary vein isolation procedure code does not need to be reported by itself, its definition establishes that it includes transseptal catheterization as well as atrial pacing and recording. Because of this, it would not be appropriate to report these services in addition to code 93656: LA pacing and recording (93621) and transseptal catheterization (93642).

Other than pulmonary vein isolation, all SVT ablations are still considered equal as far as the basic procedure is concerned. AVNRT, WPW, and atrial flutter ablations are lumped together under code 93653. Similar to the code for pulmonary vein isolation, code 93653 has a “honey do” list of procedural components that must be performed in addition to the ablation procedure. The ablation itself is defined as “ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavotricuspid isthmus or other single atrial focus or source of atrial re-entry.” Here is the “honey do” list:

Induction or attempted induction of an arrhythmia

Right atrial pacing

Right atrial recording

Right ventricular pacing

Right ventricular recording

His recording 

The 52 modifier should be applied to 93653 when less than the full list of procedural components is performed and documented. Also similar to the AF ablation procedure coding, the add-on code 93655 can be reported in addition to this SVT ablation code for additional lesions created after the basic ablation procedure is complete.

The other new basic ablation code CPT 2013 introduces is 93654. This is the new package code we’ll use to report ventricular tachycardia ablations. In addition to each of the procedural components that are included in the new SVT ablation code, this VT ablation code also includes 3D mapping (93613) when performed and left ventricular pacing and recording (93622) when performed. Therefore, it is not appropriate to report these services in addition to the VT ablation code.

This brings us to all of the other services that are not included in the new code definitions. It is still appropriate to report Isuprel infusion (93623), 2D mapping (93609), intracardiac echo (93662), and arterial line placement (36620) when performed in addition to each of the new ablation codes. Three-dimensional mapping (93613) and left ventricular pacing and recording (93622) can also be reported with each of the new ablation codes except 93654 (the new VT ablation code). Left atrial pacing and recording (93622) and transseptal catheterization (93642) can be reported with all but the pulmonary vein isolation procedure code.

Only one pacemaker/defibrillator code was tampered with in CPT 2013; it is the add-on code (33225) we use to report the addition of a left ventricular lead to a new pacemaker or defibrillator generator. 

The first parenthetical note listed under code 33225 establishes which base procedures it can be “added on” to. Removed from the list is 33222 (pacemaker pocket revision) and added are codes 33228, 33229, 33263, and 33264. These are the generator change out codes for dual chamber pacemakers, multiple chamber pacemakers, dual chamber defibrillators, and multiple chamber defibrillators, respectively. The absence of codes 33227 and 33262 (the single chamber generator change out codes for pacemakers and defibrillators) is noted. 

Codes 33227 and 33262 are not appropriate base codes for the LV lead add-on procedure, because earlier this year the American Medical Association provided a major clarification on how to code for generator change outs that involve the addition of a left ventricular lead. In short, we were instructed to report the LV lead add-on code in addition to the generator change out code that reflects the type of system we are upgrading to (not the one we started with). If a patient has a single chamber pacemaker upgraded to a system with an RA and RV lead, we should report it as a dual chamber generator change out (33228) and the LV lead add-on code (33225). Because of this clarification, the codes for single chamber generator change out would never be appropriate — we would not put in an LV lead to upgrade to a single chamber system.

The second alteration to code 33225 comes in the form of a new parenthetical note that reads as follows: “Use 33225 in conjunction with 33222 only with pacemaker pulse generator pocket relocation and with 33223 only with pacing Cardioverter-defibrillator [ICD] pocket relocation.” You’ll also notice that the words “and pocket revision” were removed from the code definition. These related changes establish that we should report pocket revision when a pocket is relocated at the time of adding an LV lead to a new generator. 

Perhaps harder to keep up with than the new codes next year will be keeping up to date with the soon to be overhauled indications for pacemakers and defibrillators. A lot of attention has been brought to the deficiencies in the current coverage indications, and all signs point to the fact that the policies are soon to be updated. Expanded indications for dual chamber pacemakers and clarification regarding the stipulations of primary prevention defibrillator implants are eminent. With all the attention afforded left ventricular leads this year, a policy for biventricular pacing is probably not too far into the future. 

It will be critical to stay on top of these developments as they happen, since Medicare Administrative Contractors and the Department of Justice are aggressively auditing to identify and prosecute derivations from the embattled and outdated National Coverage Determinations. 


RhondaSsays: January 24.2013 at 14:55 pm

Hi,
I have a question for Jim Collins regarding his Volume 13 issue 1 January 13 Changes Coming for 2013 CPT codes. I have advised our EP physicians not to report 93623 with the new ablation cpt codes. Would this be correct?

The newly updated Revision Date 1/1/2013 Chapter XI Medicine National Correct Coding Initiative, page XI- 20, # 29. (states) CPT code 93623 (programmed stimulation and pacing after intravenous drug infusion) is an add-on code that may be reported per CPT Manual instructions only with CPT codes 93619 or 93620 (comprehensive electrophysiologic evaluation). CPT code 93623 should not be reported for injections of a drug with stimulation and pacing following an intracardiac catheter ablation procedure (e.g., CPT codes 93650-93657) to confirm adequacy of the ablation. Per CPT Manual instructions, CPT code 93623 is not intended to be reported with the intracardiac catheter ablation procedure codes, and confirmation of the adequacy of ablation is included in the intracardiac catheter ablation procedure.

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Jim Collinssays: January 28.2013 at 13:03 pm

The new CCI publication cements in three errors in the CPT framework. By validating the previously considered parenthetical note errors in CPT which excluded the ablation codes (93650-93657) from the applicable base codes for the add-on procedures (93621-93623) CCI has essentially made it inappropriate to report LA pacing/recording, LV pacing/recording, and Isuprel infusion at the time of an ablation. Therefore, it is correct to tell your providers to not report these services separately.

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girouarksays: January 29.2013 at 14:12 pm

Jim:

So if this is an error on CPT's part, which it sounds like it is, is CCI edits going to correct their edit so that we can bill 93621-93623 eventually? Will we ever be able to report these codes with the ablation codes 93650-93657.

I'm confused at this whole mess CPT has created.

Thanks Jim.....

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Jim Collinssays: February 4.2013 at 10:13 am

Since the NCCI manual was updated to re-enforce the parenthetical notes, I do not anticipate that the CCI edits will reverse/correct them. This effectively makes it inappropriate to report 93621 - 93623 with the new ablation codes. Jim.

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TerryFletcherCPCsays: February 16.2013 at 14:42 pm

Hi Jim,
Thank you for your article and insights into EP. This was a very helpful article and I direct my clients to it daily. I have a question based on the thread above, that I would like to run by you because I am also seeing that CPT and CCI have some conflicting instructions. I get that the code 93621 is bundled into the ablation codes. But my question is regarding the 93623 for the programmed stimulation during the 93656 ablation for Afib. The CPT book (page 519 2013 Prof edition second to last paragraph) states, "...codes 93622 and 93623 may be reported separately with 93656 for treatment of afib...." and there is a -59 modifier edit allowed for the 93623. Also the parenthetical codes underneath the 93656 does not exclude the 93623 from being coded with 93656. BUT, and there always a but, I am seeing this being denied when coded with the ablation code.
Do you see a scenario when it is appropriate to code for it with an SVT or VT ablation? Medicare or non-Medicare.
Thanks for your response in advance.

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Rachelsays: February 22.2013 at 11:06 am

Jim,
What code would be appropriate to use for an aflutter ablation?

Reply to this comment »
Jim Collinssays: February 22.2013 at 17:06 pm

CMS Transmittal 2636, with an effective date of April 1, 2013, will put an end to separate payment for five common add-on services in the electrophysiology world. The 2013 codes for ablation bundle the work of a diagnostic EP study in with the work of the ablation. However, CPT instructions made it clear that mapping and other common add-on services could be reported in addition to the composite ablation codes. Consider the following excerpts from CPT 2013:

“Mapping is a distinct procedure performed in addition to a diagnostic electrophysiology study or ablation procedure and may be separately reported using 93609 or 93613.”

“Codes 93622 and 93623 may be reported separately with 93656 for treatment of atrial fibrillation.”

Although CPT says that we can bill these four services with the new ablation codes, Transmittal 2636 establishes otherwise. The transmittal classifies add-on codes into different Types. The add on codes for 2D mapping (93609), 3D mapping (93613), LA pace/record (93621), LV pace/record (93622), and drug infusion followed by induction attempts (93623) are each categorized as “Type I” add-on services.

According to the transmittal, “A Type I add-on code has a limited number of identifiable primary procedure codes. The CR lists the Type I add-on codes with their acceptable primary procedure codes… Claims processing contractors must adopt edits to assure that Type I add-on codes are never paid unless a listed primary procedure code is also paid.”

The transmittal also lists which specific primary procedure codes are recognized for payment purposes. The table summarizes our five add-on services in the following way:

93609 is reported with 93620, 93653
93613 is reported with 93620, 93653
93621 is reported with 93620
93622 is reported with 93620
93623 is reported with 93619, 93620

Other than being able to report mapping (93609 or 93613) with the new SVT ablation code (93653), we should not be reporting any of these five add-on services with any of the new ablation codes. This represents a substantial reduction in reported RVUs and the associated revenue.

A CMS representative confirmed that Medicare rule can override CPT instruction and alluded to the potential for additional clarification from the AMA with the following comment, “there may be additional guidance from the AMA on both issues shortly. If there is not, CMS usually goes with the published CPT guidance unless there is a Medicare rule that contravenes the guidance.”

In addition to Transmittal 2636, the Correct Coding Initiative Policy Manual (Chapter XI) also contravenes CPT instruction. The CCI publication states the following, “Per CPT Manual instructions, CPT code 93623 is not intended to be reported with the intracardiac catheter ablation procedure codes”.

All things considered, this appears to be pretty conclusive. CMS instructions override CPT instructions and CMS says we cannot report these add-on services with the new ablation codes.

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Jodysays: July 24.2013 at 11:43 am

I am getting denials for 93650 and 93609, would there be a reason that we cannot bill these together? i do not see anything in the CCI book.
thank you,
Jody

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Sharon Oliversays: March 26.2013 at 09:22 am

Jim,

My physician has asked for the code for Isuprel Challenge. Would you please help me to accurately bill for this.

Many thanks,
Sharon

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Reshena Gsays: January 9.2014 at 21:21 pm

Can you please explain CPT 93657 and CPT 93655 a little bit more in details. I need help understanding when to use to CPT codes. What do I need to look for in OP note to be able to use these add-on codes?

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