Like EP Lab Digest, I entered the world of electrophysiology 20 years ago. My introduction on day one was as the compliance analyst at The Care Group in Indianapolis. My first marching orders were to get up to speed on EP coding rules and to conduct auditing and education to confirm accurate documentation and coding. I didn’t know what “EP” stood for.
Twenty years ago, electrophysiology coding guidance was limited and contradictory. Medicare publications said one thing, the American Medical Association (AMA) said another, and the North American Society of Pacing and Electrophysiology (NASPE) said a third. Getting up to speed on EP coding was one of the biggest challenges of my career. In addition to learning EP anatomy, physiology, and procedural techniques, I had to reconcile the contradictory guidelines by working with the people who published them.
Since then, the most significant changes to EP procedure coding came in 2013 when the AMA introduced monolithic codes to report ablation procedures.
Prior to 2013, it was appropriate to separately report each of the individual components of the procedure: the diagnostic EP study, mapping, left atrial pacing and recording, and ablation. Coding options for ablations were limited to the AV node, supraventricular tachycardia (SVT), or ventricular tachycardia (VT), so reimbursement for atrial fibrillation (AF) ablations was the same as other SVT ablations.
The most significant new code of 2013 was 93656, which is defined as “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.”
The service described by this new code includes AF ablation and many of the other services typically performed during an AF ablation. Mapping, drug infusion with attempted induction, and intracardiac echo (ICE) are the main exceptions; they are separately reportable. When I first read the definition of the new code, I was alarmed. I instantly realized that the new code would routinely cut reimbursement for AF ablations and necessitate a tremendous amount of administrative burden to get claims processed.
The service described by code 93656 includes a “comprehensive electrophysiologic evaluation.” The CPT book established that a comprehensive EP evaluation included 6 components: RA recording, His bundle recoding, RV recording, RA pacing, RV pacing, and attempted induction of an arrhythmia. When less than all 6 components are performed and documented, it was necessary to affix the reduced service modifier (52). When this modifier was used, it would automatically trigger a denial of the service and a request for additional documentation to adjudicate the claim. In addition to delaying payment for months, this approach allowed several claims to fall through the cracks and it almost always reduced compensation, sometimes by 50%.
The concern is that many AF ablation procedures do not include all 6 components of a “comprehensive electrophysiologic evaluation.” For many AF patients, there is no medical necessity to cross the tricuspid valve during an AF ablation. As initially introduced, code 93656 would frequently need to be reported with the reduced service modifier (52), or physicians would need to perform all of the components of a comprehensive EP study in order to secure full compensation and to avoid months of claim processing delays and lost revenue. I did not like these options, because one virtually guaranteed lost revenue and the other involved avoidable procedural risk.
Before the codes became effective, I reached out to CMS, the AMA, and the Heart Rhythm Society. I explained the concerns mentioned above, and illustrated how the inclusion of a comprehensive EP study in the definition of code 93656 would derail the intent of the new packaged CPT code. My effort resulted in the following instructions being added to CPT: “Code 93656 includes each of left atrial pacing/recording, right ventricular pacing/recording, and His bundle recording when clinically indicated. When performance of one or more components is not possible or indicated, document the reason for not performing.” As such, a simple statement in the procedural report that says something like, “Any components of a comprehensive EP study not documented above were not indicated for this patient” eliminates the need to perform unnecessary EP study components or to delay and reduce compensation. This standard still applies today.
Also introduced in 2013 were “add-on” codes 93655 and 93657. These are to be reported in addition to the appropriate “base procedure” code. It is appropriate to report these add-on codes when a base procedure is completed, an arrhythmia is still present, and the doctor performs another ablation to treat the remaining arrhythmia.
Code 93657 is defined as “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.” This add-on code may only be reported in addition to the code for AF ablation (93656). Currently, this code may be reported 2 times per procedure. At $434 (2021 National Physician Fee Schedule), reporting code 93657 twice generates additional payment equivalent to 76% of the $1,145 reimbursement for the AF ablation (93656). Code 93655 (also $434) is similar to code 93657 — it should be reported for an add-on ablation of any non-AF arrhythmia. Code 93655 may also be reported twice, and it could be reported in addition to SVT, AF, or VT ablation codes. For some procedures, reimbursement for the add-on codes eclipses the reimbursement for the base procedure.
There was no code specific to left ventricular lead implants for about 2 years after the procedure started to be performed. Through trial and error, I created an effective claim filing technique during that period. For each procedure, I reported an unlisted CPT code (33999 - Unlisted procedure, cardiac surgery) and flooded payers with hundreds of pages of supporting documentation from the FDA, device companies, and specialty societies. I put a clearly worded, 1-page cover letter on top of the stack of supporting documentation; it clearly illustrated how the service was medically necessary as defined under the Social Security Act, FDA approved, and not investigational. It worked about 90% of the time.
I observed a left ventricular lead implant so I could more clearly explain the procedure to payers. When the device rep for the case heard I was having success with billing, he set up a meeting with his boss who facilitated a consulting relationship with the device company. In that role, I helped secure listed CPT codes for left ventricular lead procedures (33224, 33225, and 33226) and later for remote monitoring (93294, 93295, 93296, 93297, 93298, and 93299).
The remote monitoring CPT codes were enthusiastically ushered in by Medicare. After we presented the clinical data, Medicare officials quickly recognized how beneficial these services would be for patients — they saw the potential to save money through reduced admissions and early responses to detected events. Knowing that it would likely take 2 years for the remote monitoring codes to be created, Medicare instructed us to report remote monitoring services with the same codes as in-person device checks.
Using the existing CPT codes was preferable to an unlisted code but not ideal, because Medicare had frequency limits that precluded us from reporting more than 4 routine defibrillator checks, 1 routine single-chamber pacemaker check, or 2 routine dual-chamber pacemaker checks each year. It became fairly common to perform 2 in-person device checks and to report 2 remote monitoring services each year. Currently, it is appropriate to report 4 remote monitoring services and as many in-person checks as the physician feels are medically appropriate (frequently 1 or 2 each year).
In the last few years, we converted from ICD-9 to ICD-10, office visit documentation standards were overhauled, peri-procedural device reprogramming codes were introduced, 3D mapping was assigned a code, reporting of generator change outs was changed to a single code, and moderate sedation became separately payable. New technology also drove several recent changes to the code structure. We saw new codes established for subcutaneous defibrillators, leadless pacemakers, cardiac contractility modulation, left atrial occlusion device, and barostim therapy.
The AMA introduced 8 new codes for use during 2021 and beyond. The new codes are used to report periods of continuous cardiac monitoring that are longer than the 24 to 48 hours referenced in the previous edition of the CPT book. Codes 93241-93244 are used to report monitoring that is longer than 48 hours up to 7 days, and codes 93245-93248 are to be used for monitoring periods that are longer than 7 days, up to 15 days.
Although there have been many changes to accommodate new technology, some procedures have become commonplace without securing a CPT code. His bundle pacing, left bundle pacing, and combined epicardial and endocardial VT ablation stand out as the most significant. There has been no guidance from Medicare or the AMA regarding how these procedures should be reported.
Some believe that attaching the unusual procedure modifier (22) to existing device implant codes is the right way to bill for His bundle and left bundle pacing. If you use this approach, keep on top of requests for supporting documentation, keep track of how much you get paid, and how long it takes to get paid. I anticipate that many will find that the 22 modifier is not worth it. If you are in this camp, report the appropriate pacemaker implant code without the 22 modifier.
It appears best to report the endocardial portion of the combined epicardial and endocardial VT ablation with the regular VT ablation code (93654). The epicardial portion of the procedure is best captured by unlisted CPT code 33999 (Unlisted procedure, cardiac surgery). Epicardial VT ablation is not pericardiocentesis, so it should not be reported as such. The claim filing process for these “unlisted procedure” codes should be similar to the one described above, specific to left ventricular lead implantation. Thanks to HIPAA, the supporting documentation needed for unusual and unlisted procedures may now be submitted electronically with the original claim.
EP coding has evolved a lot, and it will continue to change as new technology and procedural techniques become mainstream. EP Lab Digest has done a great job of keeping readers up to date on these topics for 20 years. Congratulations on celebrating 20 years in print!
Jim Collins, CPC, CCC is a consultant with CardiologyCoder.Com, and works exclusively with cardiology documentation, coding, and reimbursement. Jim provides education and auditing services to healthcare providers, as well as health economics and reimbursement support for the device industry.
Disclosures: The author has no conflicts of interest to report regarding the content herein.