2013 Coding Changes and Compliance Update for Electrophysiology Services

Transcription

1 2013 Coding Changes and Compliance Update for Electrophysiology Services presented by Sheila Sylvan reimbursement, payment, or charge 2012 IMPACT 1 Faculty / Planner Disclosure Sheila Sylvan Laura Driscoll IMPACT Medical Consulting Serve as outside faculty for educational programs hosted by Cordis Corporation and Biosense Webster, Inc. Have no other relevant financial relationships with commercial interests IMPACT 2 IMPACT

2 Disclaimer The information in this presentation is broad based and intended to address a wide range of reimbursement situations that you may encounter. In some areas, Biosense Webster may not have products approved for certain indications/procedures discussed. Please refer to any package insert for a complete description of indications and contraindications for each medical device used. The information is provided to assist you in understanding the reimbursement process. It is intended to assist providers in accurately obtaining reimbursement for health care services. It is not intended to increase or maximize reimbursement by any payor. We strongly suggest that you consult your payor organization with regard to local reimbursement policies. The information contained in this document is for informational purposes only and represents no statement, promise, or guarantee by Biosense Webster or IMPACT concerning levels of reimbursement, payment or charge. Similarly, all CPT and HCPCS codes are supplied for information purposes only and represent no statement, promise or guarantee by Biosense Webster or IMPACT that these codes will be appropriate or that reimbursement will be made IMPACT 3 Coding for Electrophysiology 2012 IMPACT 4 IMPACT

3 Conduction System of the Heart 1 Sinoatrial (SA) Node 6 2 Atrioventricular (AV) Node Right Bundle Branch Purkinje Fibers 2 5 Left Bundle Branch 6 His Bundle 3 4 Cordis Corporation IMPACT 5 Diagnostic Electrophysiology Procedures Noninvasive programmed electrical stimulation [NIPS] Catheter-based invasive electrophysiologic testing [EPS] Cardiac mapping Intracardiac echocardiography [ICE] Other diagnostic procedures on heart and pericardium Items coded additionally: Any concomitant procedures Synchronous Doppler flow mapping (88.72) with ICE 2012 IMPACT 6 IMPACT

4 Diagnostic Intracardiac Electrophysiology Procedures / Studies Electrophysiological Study: Individual measurements His bundle recording Intra-atrial recording Right ventricular recording Intra-atrial pacing Right ventricular pacing Comprehensive study Arrhythmia induction vs Add-on codes with left atrial pacing / recording with left ventricular pacing / recording 2012 IMPACT 7 Diagnostic Intracardiac Electrophysiology Procedures / Studies Mapping vs Programmed stimulation after drug infusion Other Electrophysiological Services Follow-up Study Intra-operative Evaluation of ICD Tilt table evaluation Intracardiac echocardiography IMPACT 8 IMPACT

5 Electrophysiology Procedures Please Note: The case study examples are provided only to illustrate possible coding and reimbursement scenarios. They are not intended as direction on how to conduct a procedure. Individual procedures will vary based on the physician s medical judgment. Medical necessity and appropriateness of any procedure is always specific to the facts of the individual case and as determined by the physician. The following case studies are derived from de-identified actual patient procedure documentation, and are therefore sometimes lengthy. The full text is included as examples of types of documentation which could be encountered; however, this presentation will focus on identification of key terms for coding purposes, not line-byline review or clinical evaluation IMPACT 9 Case #1: Diagnostic Electrophysiology Study HISTORY: The patient is a pleasant, middle-age male who has had near syncopal events associated with palpitations. He has thus far had extensive evaluation, including echocardiogram and cardiac MRI showing structurally normal heart. He has had an equivocal tilt table testing showing vasodepressive response but not clinically matching his episodes. He has had prior event monitoring, which has shown wide complex sinus tachycardia that looked to be artifactual on analysis, with no clear correlation to symptoms. Given frequency of symptoms and the fact that the patient is a public transit driver we proceeded to do further evaluation with cardiac electrophysiology testing to see if he has any atrial or ventricular arrhythmias and assess his sinus node, AV node function. His baseline QT interval is msec, and there is no family history of any type of arrhythmias. PROCEDURE: We brought patient to cardiac electrophysiology lab. Extensive risk and benefit discussion provided, informed consent obtained. Access was gained in the right femoral vein x3. Advanced a quadripolar catheter to the RA, His and RV positions IMPACT 10 IMPACT

6 Case #1: Diagnostic Electrophysiology Study Baseline numbers are as follows: AH interval 160 msec, HV interval 48 msec, PR interval 200 msec, QRS duration of 89 msec, QT interval 390 msec. Sinus node recovery time at 500 msec was 1260 msec, at 600 msec drive train was 389 msec, at 700 msec drive train was 1400 msec. AV block cycle length 410 msec above the AV node, AV node EPT 350 msec at 700 msec at baseline. No evidence of dual AV node physiology. The patient had interatrial echoes 1-2 beats. No sustained arrhythmias, even after isoproterenol administration, and repeat of the AV node ERP. VA block cycle length at baseline was greater than 600 msec. We did triple extrastimulation in the ventricle on isoproterenol at 3 drive trains. We had no induction of any ventricular arrhythmia. Straight ventricular pacing with isoproterenol administration did not induce any ventricular arrhythmias. CONCLUSION: This is a negative EP study, normal conduction system, normal AV node function, normal HV function, and no significant arrhythmias. At this point, we are going to continue to monitor the patient. Will make a reassessment over time IMPACT 11 Case #1: Diagnostic Electrophysiology Study Procedure Procedure Coding Physician / Outpatient Inpatient Diagnosis Comprehensive EP study with induction of arrhythmia Programmed stimulation and pacing with IV drug /TC /TC Notes: Although no arrhythmias were induced, the descriptor for states, induction or attempted induction of arrhythmia. Therefore, this code is appropriate even when an attempt is not successful IMPACT 12 IMPACT

7 Therapeutic Electrophysiology Procedures Excision or destruction of other lesion or tissue of heart, open approach Excision or destruction of other lesion or tissue of heart, endovascular approach Excision or destruction of other lesion or tissue of heart, thoracoscopic approach 99.6x Conversion of cardiac rhythm Atrial Cardioversion Other electric countershock of heart 2012 IMPACT 13 Therapeutic Electrophysiology Procedures Ablation Significant Revisions for AV node ablation Comprehensive EPS with atrial ablation, single focus Comprehensive EPS with ventricular ablation, includes 3-D mapping, LV pacing & recording Ablate additional discrete arrhythmia focus Comprehensive EPS with pulmonary vein isolation for Afib, includes transseptal access Additional left or right atrial focus for Afib Note: Operative EP Interventions Open Endoscopic Intraoperative EP study Cardioversion Cardioversion for an arrhythmia which is intentionally induced (eg, as part of a diagnostic EP study) is not reported. THERMOCOOL Naviga@on Catheters are approved for drug refractory recurrent symptoma@c paroxysmal atrial fibrilla@on, when used with CARTO Systems (excluding NAVISTAR RMT THERMOCOOL Catheter) IMPACT 14 IMPACT

8 Case #2: Electrophysiology Study and Radiofrequency Ablation PROCEDURE: 1. Complete electrophysiology study, diagnosis of typical AV nodal reentrant tachycardia, with successful ablation of the slow pathway. 2. Additional diagnosis of atrial tachycardia, mitral annular atrial tachycardia, with successful ablation HISTORY: The patient is a pleasant 69-year-old female who has been having recurrent episodes of SVT, at times having near syncopal events with her tachycardia, which is unusual. She has a structurally normal heart. She has had documented narrow complex tachycardia. She has tried medications without success and the patient prefers not to be on medications long term. PROCEDURE: After risk and benefit discussion, the patient was brought to the Cardiac Electrophysiology Laboratory. With the help of our colleagues she was sedated. Access was gain to right femoral vein without difficulty. Quadripolar catheters were advanced to the RA, His and RV position IMPACT 15 Case #2: Electrophysiology Study and Radiofrequency Ablation These are the baseline numbers: HV interval of 58 msec, AH interval of 140 msec. At baseline the patient interchanged between long AH and short AH, suggestive of presence of a slow pathway. AV block cycle length at baseline was 340 msec. The patient conducted over the slow pathway for the QRS and maintained this. AV nodal ERP was evaluated. Fast pathway ERP 380 at 600 msec. Large window with slow pathway blocking at 260 at 650 msec. VA block cycle length was 440 msec. There was notation of a retrograde jump and VA ERP was decremental concentric, less than 300 at 500 msec. Narrow complex tachycardia VA timing of 67 msec. Was induced on isoproterenol 2 mcg, reproducibly with straight atrial pacing to conduction over the slow pathway. We entrained the tachycardia, obtained a V-A-V response with a PPI of greater than 120 msec, confirming the diagnosis of typical AV nodal reentrant tachycardia. After this we proceeded to use 3 dimensional mapping and marked the His region. We then under electroanatomic guidance and electrophysiological guidance proceeded to the slow pathway region. Ablation in the slow pathway led to junctional beats with 1:1 conduction. After ablation of the slow pathway we no longer had conduction over the slow pathway, could no longer sustain over the slow pathway with straight atrial pacing and we had non-inducibility IMPACT 16 IMPACT

9 Case #2: Electrophysiology Study and Radiofrequency Ablation We again attempted the ventricular single extrastimulation, did induce another tachycardia with slower cycle length. The tachycardia cycle length for the AVNRT was 320 msec. The slower tachycardia was at a rate of 120 beats per minute. P-waves are noted to be negative in I and a VL suggestive of the left-sided focus. Initially we mapped the coronary sinus. Ablation in the distal coronary sinus was unsuccessful. With suggestion of potential mitral annular tachycardia reproducibly induced on isoproterenol, we then proceeded to make a transseptal puncture at the 4 o clock position, using fluoroscopic guidance and pressure guidance without difficulty. We then proceeded to use early mapping and activation mapping using 3-D mapping system, found an area of -58 msec from the surface P-wave. Ablation in this area led to acceleration of the a1 tachycardia and break. We then continued to test on isoproterenol and had no induction of atrial tachycardia or AVNRT. This should portend good long-term prognosis. In so far as AVNRT, she should have a <5% chance of recurrence. In so far as atrial tachycardia, there is a 10-20% chance of recurrence at times. The patient tolerated the procedure well. There were no immediate complications IMPACT 17 Case #2: Electrophysiology Study and Radiofrequency Ablation Procedure Procedure Coding Physician / Outpatient Inpatient Comprehensive EP Study with induction of arrhythmia /TC Intracardiac atrial ablation Programmed stimulation after IV drug /TC /TC Included in D intracardiac mapping /TC /TC Diagnosis Transseptal puncture N/A Ablate discrete arrhythmia mechanism Bundled Included in IMPACT 18 IMPACT

10 Case #2: Electrophysiology Study and Radiofrequency Ablation Case Notes: Code is most accurate diagnosis code to report both AV nodal reentrant tachycardia (AVNRT) and other atrial tachycardia not documented as paroxysmal, as noted in study findings. Documentation describes well that there are two distinct pathways, thereby supporting 93655, even with only a single ICD-9-CM diagnosis code. Statements regarding the coronary sinus and left atrial evaluation all use the term mapping, rather than pacing and recording, so is not clearly supported; clarification with physician to confirm would be appropriate IMPACT 19 Case #3: Electrophysiology Study and Radiofrequency Ablation INDICATIONS: The patient is a 38-year-old female, who presented 3 months ago with episodes of sustained ventricular tachycardia EKG suggestive of idiopathic RVOT tachycardia. She has undergone extensive evaluation including echocardiogram and cardiac MRI showing essentially a normal cardiac function and cardiac structure. She has been on beta blockers and having significant symptoms of fatigue and tiredness, additionally to having breakthrough palpitations. We discussed risks and benefits of an ablation procedure. After extensive discussion, she opted to proceed with ablation. PROCEDURE IN DETAIL: She was brought to the cardiac electrophysiology laboratory. We initially placed the patient on the table, placed her on isoproterenol upwards of 6 mcg, where we induced sustained tachycardia. Again the 12-lead matching her prior clinical tachycardia and suggestion of a septal RVOT tachycardia. We then gained access in the right femoral vein x3. Quad catheter advanced to the RV apex. Decapolar catheter placed in the coronary sinus to serve as a reference catheter for 3-D mapping IMPACT 20 IMPACT

11 Case #3: Electrophysiology Study and Radiofrequency Ablation We then used a 4 mm large curved catheter, created the shell of the RV outflow tract, and began to pace map in sinus rhythm off isoproterenol. We found 12/12 pace map match in the lower septal region of the RVOT. We then placed the patient on isoproterenol and we performed activation mapping, which showed us to be in this region 40 msec ahead of the QRS initiation, suggesting a good site for ablation. We turned isoproterenol off, ablated in this region where we obtained essentially bigeminy pattern with the same PVC morphology. We created a small cloud around this lesion and where we had good pace maps. We then placed the patient again on isoproterenol, upwards of 6 mcgs, and at the critical heart rate of 120 where she had had before ventricular tachycardia. She did not have any further episodes of ventricular tachycardia or PVCs. We observed the patient on isoproterenol. Again, no sustained tachycardia at the end of the procedure. This portends a good prognosis and good long term outcome. We then pulled the sheath out without difficulty. The patient is to taper down her beta blocker therapy, to follow up with me in 1-2 weeks after the procedure IMPACT 21 Case #3: Electrophysiology Study and Radiofrequency Ablation Procedure Comprehensive EP Study with induction of arrhythmia, reduced Procedure Coding Physician / Outpatient / TC-52 Inpatient Intracardiac ventricular ablation (-52) D intracardiac mapping /TC Included in Programmed stimulation after IV drug /TC /TC Diagnosis Case Notes: For 2013, new ventricular ablation code includes both comprehensive EP study and 3-D mapping, so is not reported additionally. Parenthetical note also indicates as bundled IMPACT 22 IMPACT

12 Case #3: Electrophysiology Study and Radiofrequency Ablation Case Notes Continued: Per CPT parenthetical notes, isoproterenol stimulation (93623) may only be reported in combination with or However, documentation discusses findings of ventricular only, so comprehensive study may be more appropriately reported with modifier alternative to is 93603, 93612, and 93618, but this would prevent reporting of This is a possible oversight in 2013 CPT, as several of the new ablation codes include comprehensive EP study as a component, and do not exclude concurrent reporting of in the parenthetical notes following the ablation procedures IMPACT 23 Case #3: Electrophysiology Study and Radiofrequency Ablation Case Notes Continued: CPT Network guidance recommends reporting a comprehensive study code with modifier -52 when it is reduced at the physician's discretion; it should be noted that payor policy regarding use of modifier -52 on these codes may vary, and reporting by this method may lead to a request for documentation. Confirm with physician and via ancillary documents for complete information before assigning codes or assuming study is reduced. Documentation improvement could include: Prompts for Narrative Input of Data "Quad was advanced to the right atrium, His position, and RV apical position. HA interval of, HV interval of, PR interval of, QRS duration of, QT interval of, AV block cycle length at baseline was. Tables Baseline Intervals R-R QT PR AH QRS HV AV block cycle Slow pathway ERP Fast pathway ERP 2012 IMPACT 24 IMPACT

13 Case #4: Electrophysiology Study and Radiofrequency Ablation PROCEDURE: Pulmonary vein isolation for persistent atrial fibrillation. INDICATIONS: The patient is a pleasant 61-year-old female who developed atrial fibrillation about 2 months ago, had rapid ventricular response and development of cardiomyopathy. She failed cardioversion and subsequently was on (medication) for a period of time. However, she had a delayed reaction to (medication) with torsade. Having failed antiarrhythmic therapy and persistent symptoms, we attempted rate control strategy with (medications) for rate control. Her LV function is somewhat improved to about 40%. She persisted to have significant symptomatology, especially with exertion and this is believed to be related to atrial fibrillation and tachy myopathy. Therefore, discussed the option of proceeding with an ablation strategy. PROCEDURE: We brought the patient after extensive risk and benefit discussion for ablation procedure. With the help of our anesthesia colleagues she was sedated. NAVISTAR THERMOCOOL Navigation Catheters are approved for the treatment of drug refractory recurrent symptomatic paroxysmal atrial fibrillation, when used with CARTO Systems (includes EZ STEER THERMOCOOL NAV Catheters. Excludes all RMT THERMOCOOL Catheters) IMPACT 25 Case #4: Electrophysiology Study and Radiofrequency Ablation Access was gained in the right femoral vein x 1 and 3 access points in the left femoral vein x3 without difficulty. A duodecapolar catheter was advanced to the distal coronary sinus to serve as a reference for 3-D mapping. Intracardiac ultrasound catheter used for our transseptal puncture. We placed a decapolar catheter for pacing of the phrenic in the setting of pulmonary vein ablation. We then crossed in the 4 o clock position using a (brand) system, crossed without difficulty. We then proceeded to create a small shell of the pulmonary veins and merged with a prior obtained CT angiogram of the pulmonary veins. We then isolated all 4 pulmonary veins, confirming isolation of the veins. There was some organization of atrial fibrillation. At this point, I had made a decision that having isolated all 4 pulmonary veins we would cardiovert the patient, and see if she would have any triggers on maximal isoproterenol, before making the decision about more extensive ablation that would include the posterior wall and coronary sinus. This is her first ablation procedure and I would like to target her pulmonary vein and antral regions, which were very will targeted with (brand) ablation. THERMOCOOL Naviga@on Catheters are approved for drug refractory recurrent symptoma@c paroxysmal atrial fibrilla@on, when used with CARTO Systems (excluding NAVISTAR RMT THERMOCOOL Catheter) IMPACT 26 IMPACT

14 Case #4: Electrophysiology Study and Radiofrequency Ablation We then converted the patient after having isolated all 4 pulmonary veins, place her on isoproterenol up to 20 mcg. She had no significant ectopy that would be of concern for triggers. I am going to start the patient on very low dose of (medication, dosage) in addition to her (medication). If she has recurrence of atrial fibrillation, she will need much more extensive substrate modification at that time. Prior to the procedure, I want to make a note, she had a transesophageal echocardiogram that showed no evidence of left atrial appendage thrombus. She had mild to moderate mitral regurgitation, and she does have left atrial enlargement that is mild to moderate. ACTs were over 350 throughout the entirety of the procedure. Protamine sulfate reversal was done, sheaths were pulled, there were no immediate complications. The patient tolerated procedure well. Again successful pulmonary vein isolation of all 4 pulmonary veins, cardioversion 200 joules, subsequent administration of isoproterenol up to 20 mcg with no significant atrial ectopy. The patient has maintained sinus rhythm. We had in the past failed to maintain sinus rhythm with just cardioversion and no antiarrhythmic therapy. This certainly encourages me and I am hoping she will have good success with this procedure. THERMOCOOL Naviga@on Catheters are approved for drug refractory recurrent symptoma@c paroxysmal atrial fibrilla@on, when used with CARTO Systems (excluding NAVISTAR RMT THERMOCOOL Catheter) IMPACT 27 Case #4: Electrophysiology Study and Radiofrequency Ablation Procedure Intracardiac atrial ablation, extensive Procedure Coding Physician / Outpatient Inpatient Transseptal puncture N/A Follow-up EP study to test effectiveness of therapy Programmed stimulation after IV drug /TC 3-D intracardiac mapping /TC /TC Intracardiac ultrasound /TC /TC Diagnosis External cardioversion Transesophageal echocardiogram /TC /TC IMPACT 28 IMPACT

15 Case #4: Electrophysiology Study and Radiofrequency Ablation Case Notes: The U.S. Food and Drug Administration (FDA) announced on February 6, 2009, that it had approved the first ablation catheters Biosense Webster s NAVISTAR THERMOCOOL and EZ STEER THERMOCOOL NAV Catheters for the treatment of drug refractory symptomatic paroxysmal atrial fibrillation (AF). NAVISTAR THERMOCOOL Navigation Catheters are approved for the treatment of drug refractory recurrent symptomatic paroxysmal atrial fibrillation, when used with CARTO Systems (includes EZ STEER THERMOCOOL NAV Catheters. Excludes all RMT THERMOCOOL Catheters). Although specific codes have been added to CPT in 2013, individual payor coverage policy should be confirmed. Currently, ICD-9-CM procedure coding for any catheter ablation will be Coverage and reimbursement will likely vary between plans. There is no particular discussion of baseline pacing or recording in this note, and isoproterenol study can only be reported in conjunction with a comprehensive EP study. Since the isoproterenol study was done after ablation, an alternative for 2012 is reporting as THERMOCOOL Naviga@on Catheters are approved for drug refractory recurrent symptoma@c paroxysmal atrial fibrilla@on, when used with CARTO Systems (excluding NAVISTAR RMT THERMOCOOL Catheter) IMPACT 29 Case #4: Electrophysiology Study and Radiofrequency Ablation Case Notes Continued: The new 2013 ablation procedure for atrial fibrillation states that it includes a comprehensive EP evaluation. CPT Network information notes that "it is usually proper to perform a complete study once a sinus rhythm is obtained after cardioversion or ablation for atrial flutter and fibrillation. This is to ensure that there is not a hidden accessory pathway or another problem. If atrial and ventricular pacing is done before or after the ablation, the code for a complete electrophysiologic study can be reported." Therefore, measurements recorded following ablation may also serve to document diagnostic EP studies performed. Would recommend clarifying with the physician regarding extent of pacing/ recording performed, both before and after ablation. Cardioversion addresses underlying native arrhythmia, which was not induced, so may be reported additionally with modifier -59. Although brief findings for the transesophageal echocardiogram are noted, a formal written interpretation report would be expected in the patient s record. THERMOCOOL Naviga@on Catheters are approved for drug refractory recurrent symptoma@c paroxysmal atrial fibrilla@on, when used with CARTO Systems (excluding NAVISTAR RMT THERMOCOOL Catheter) IMPACT 30 IMPACT

16 Case #5: Electrophysiology Study and Radiofrequency Ablation PROCEDURE: Pulmonary vein antral isolation and a cavotricuspid isthmus flutter ablation. HISTORY: The patient is a pleasant 44-year-old male who has had refractory atrial fibrillation to maximal doses of Class 1C antiarrhythmic (medication) in addition to recent initiation of sustained typical counterclockwise looking atrial flutter on EKG. After extensive risk and benefit discussion, the patient wants to proceed with an ablation PROCEDURE: The patient was brought to the cardiac electrophysiology laboratory ad with the help of our anesthesia colleagues he was sedated. Access was gained x3 in the right femoral vein. A decapolar catheter was advanced to the mid to distal coronary sinus to serve as a reference. We then advanced the intracardiac ultrasound to visualize the fossa in the 4 o clock position using a (brand) transseptal system without difficulty after having crossed foramen. We then gave a bolus of heparin and maintained ACT therapeutic, greater than 350 throughout the entirety of the procedure. NAVISTAR THERMOCOOL Navigation Catheters are approved for the treatment of drug refractory recurrent symptomatic paroxysmal atrial fibrillation, when used with CARTO Systems (includes EZ STEER THERMOCOOL NAV Catheters. Excludes all RMT THERMOCOOL Catheters) IMPACT 31 Case #5: Electrophysiology Study and Radiofrequency Ablation We then created a three-dimensional shell of the left atrium, pulmonary veins and appendage and in addition merged this with prior obtained CT imaging. We then proceeded to antrally isolate the pulmonary veins using irrigated 4 mm catheter. All 4 antral pulmonary vein isolations were performed and subsequent to this, we confirmed that pulmonary veins were isolated. With elimination of pulmonary vein potentials we waited up to 50 minutes and there was no recurrence of pulmonary vein connections. We then proceeded to the right side and ablated the cavotricuspid isthmus, and ablation led to bidirectional block of the cavotricuspid isthmus, greater than 120 msec block. The patient tolerated the 2 and ½ hour procedure well. There were no immediate complications. He was therapeutic on his heparin throughout the entirety of the procedure. He is to be on anticoagulation for at least 3 months post procedure. He will be maintained on low dose of (medication) post procedure for 3 months and then hopefully he will have good long-term success from his atrial fibrillation ablation IMPACT 32 IMPACT

17 Case #4: Electrophysiology Study and Radiofrequency Ablation Procedure Comprehensive EP Study with induction of arrhythmia, reduced Procedure Coding Physician / Outpatient / TC-52 Inpatient (-52) Intracardiac atrial ablation, extensive Transseptal puncture N/A Right atrial ablation Bundled D intracardiac mapping /TC /TC Intracardiac ultrasound /TC /TC Injection/infusion of anticoagulant Bundled Bundled Diagnosis IMPACT 33 Case #5: Electrophysiology Study and Radiofrequency Ablation Case Notes: This record only briefly describes diagnostic EP measurements, with any findings focused on atrial sites. The new ablation procedure for atrial fibrillation states that it includes a comprehensive EP evaluation, with atrial recording and pacing, when possible, right ventricular pacing and recording, His bundle recording. Although the term when possible implies that not all components may be required, its position in the descriptor appears to refer to atrial measurements, if possible, rather than ventricular. One option is to report code (for 2013, code 93656) with modifier 52 as reduced, since there is no indication of ventricular measurements obtained. Confirm with physician and via ancillary documents for complete information regarding extent of pacing/recording performed, both before and after ablation, before assigning codes or assuming study is reduced. THERMOCOOL Naviga@on Catheters are approved for drug refractory recurrent symptoma@c paroxysmal atrial fibrilla@on, when used with CARTO Systems (excluding NAVISTAR RMT THERMOCOOL Catheter) IMPACT 34 IMPACT

18 Device Implants and Related Procedures 2012 IMPACT 35 ICD-9-CM Pacemaker and Defibrillator Procedures Separate ICD-9-CM procedure codes exist for initial insertion, revision, replacement, or removal of leads and/or pacemaker device. In addition, temporary and permanent are differentiated by code selection, as well as single vs. dual chamber device insertions. When a permanent pacemaker device is implanted ( ), lead insertion ( ) is coded additionally. Cardioverter-defibrillators, see , which include codes describing a total system, as well as leads or generator only. Also pay attention to the codes for bi-ventricular devices, IMPACT 36 IMPACT

19 CPT Pacemaker and Defibrillator Procedures Significant revisions in CPT 2012: Indicate insertion of new or replacement... Removal of generator with immediate replacement is reported with a single code. Clarifications on use: Upgrades from dual chamber device to biventricular should be reported as generator change plus (per CPT 2012 Errata document). Revisions which change type of device (pacer vs. ICD) still separate Separate codes to indicate single, dual, or multiple lead devices Separate codes for pacemaker vs. implantable cardioverter-defibrillator Many codes for various approaches of implanting, repairing, or removing of permanent pacemakers and cardioverter-defibrillators, by each component part 2012 IMPACT New and Revised CPT Codes 0319T Insertion or replacement of subcutaneous implantable defibrillator system with subcutaneous electrode 0320T Insertion of subcutaneous defibrillator electrode 0321T Insertion of subcutaneous implantable defibrillator pulse generator only with existing subcutaneous electrode 0322T Removal of subcutaneous implantable defibrillator pulse generator only 0323T Removal of subcutaneous implantable defibrillator pulse generator with replacement of subcutaneous implantable defibrillator pulse generator only 0324T Removal of subcutaneous defibrillator electrode 0325T Repositioning of subcutaneous implantable defibrillator electrode and/or pulse generator 2012 IMPACT 38 IMPACT

20 2013 New and Revised CPT Codes 0326T Electrophysiologic evaluation of subcutaneous implantable defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters) u (Report 0326T separately during device insertion, replacement or for follow-up device testing, when performed)t 0327T Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter; implantable subcutaneous lead defibrillator system 0328T Programming device evaluation (in person) with iterative adjustments of the implantable device to test the function of the device and select optimal permanent programmed values with analysis; implantable subcutaneous lead defibrillator system 2012 IMPACT 39 Case Study # 6 Device Upgrade PROCEDURE: Upgrade of the pacemaker to a CRT-D system. HISTORY: The patient is a pleasant elderly male, who has severe ischemic cardiomyopathy in addition to valvular heart disease, which has been progressive, and ejection fraction of less than 30%. He had COPD, New York Heart Association class III, wide QRS complex, greater than 120 msec in addition to atrial fibrillation. He has had significant ventricular pacing in attempts to control his atrial fibrillation and has had worsening heart failure We had an extensive discussion about the overall long-term prognosis of the patient and the potential benefits of a defibrillator or a cardiac resynchronization system. The patient and family are insistent and would like the patient to have this in so far as trying to give him some improvement in quality of life and avoid hospitalizations for congestive heart failure. THERMOCOOL Naviga@on Catheters are approved for drug refractory recurrent symptoma@c paroxysmal atrial fibrilla@on, when used with CARTO Systems (excluding NAVISTAR RMT THERMOCOOL Catheter) IMPACT 40 IMPACT

21 Case Study # 6 Device Upgrade PROCEDURE IN DETAIL: Therefore, he was brought to the cardiac electrophysiology laboratory. With the help of our anesthesia colleagues, he was sedated. Incision was made over the left deltopectoral groove. Unipolar leads were inspected and found to be in good condition. Those leads were not to be used in his chronic atrial fibrillation. The atrial lead was was used as a cap in the new device. The RV lead was capped. We then gained access in the subclavian x 2 without difficulty. Through a sheath technique, we advanced a dual coil (brand, serial number) lead to the RV apex, sensing of 7.9, threshold 0.6V, impedance of 771 ohms. We then cannulated a coronary sinus using a (brand) sheath catheter. The patient had a significant-sized coronary sinus valve. Eventually overcoming this, we passed into the CS without difficulty. Advanced a (brand, serial number) lead to a basolateral position. No phrenic stimulation. Maximal output threshold 2.0 and 1.0 in the bipolar configuration, impedance of 1210 ohms. THERMOCOOL Naviga@on Catheters are approved for drug refractory recurrent symptoma@c paroxysmal atrial fibrilla@on, when used with CARTO Systems (excluding NAVISTAR RMT THERMOCOOL Catheter) IMPACT 41 Case Study # 6 Device Upgrade We then secured the leads to the pectoralis muscle. Connected these leads to a new (brand) defibrillator, serial number XXX. We then placed the leads and device into the pocket that was created after copious irrigation and hemostasis achieved. Then after placing leads and device into the pocket, closed in a 2 layer fashion and dressing applied. Programmed VVIR 80 beats to 130 beats per minute, VF zone 200 beats per minute, 35 dual maximal output. The patient is to complete his antibiotic course. I certainly hope the patient will have clinical benefit. We will increase his beta-blocker and digoxin level at this point. After 3 months of healing, if there is no sign of infection and he does not have biventricular pacing greater than 90%, he would benefit from AV node ablation, and we can reassess him at that time IMPACT 42 IMPACT

22 Case Study # 6 Device Upgrade Procedure Insertion or replacement of ICD system with transvenous lead(s), single or dual chamber Insertion of LV electrode at time of generator insertion Procedure Coding Physician / Outpatient Removal of pacemaker pulse generator only Inpatient Diagnosis Case Notes: When an device is upgraded involving additional leads and/or if the devices are not of the same type, both removal and insertion are reported; addition of RA or RV lead causes the insertion to be reported as a complete device rather than just the generator (33249 = generator + 1 or more leads), even if a pre-existing lead is retained. Any time a new generator is inserted, is selected for the LV electrode. If this had been an upgrade from dual chamber ICD to biventricular ICD, report as DFT testing ( /TC) not stated as performed IMPACT 43 Update on Recovery Audit Contractor (RACs) Activity and Other Payor Reviews 2012 IMPACT 44 IMPACT

23 Recovery Audit Program Activity Overpayments Collected Underpayments Returned Demo Mar 2005 Mar 2008 FY 2010 Oct 2009 Sept 2010 National Program FY 2011 Oct 2010 Sept st Qtr FY 2012 Oct 2011 Dec 2011 Total $992.7M $75.4M $797.4M $397.8M $1.27B $37.8M $16.9M $141.9M $24.9M $183.7M Total Corrections $1.03B $92.3M $939.3M $422.7M $1.45B All organizations, including facilities and physician practices, continue to report significant increases in RAC denials and medical record requests. Nearly two-thirds of medical records reviewed by RACs did not contain an improper payment. (Source: Issue descriptions as posted on RAC websites.) 2012 IMPACT 45 Prepayment Review: RAC Demonstration Project and MAC Activity During 2012, CMS has initiated a demonstration project which will allow RACs to review claims before they are paid to ensure compliance. The Florida MAC, First Coast, has already begun prepayment review on the following MS-DRG: MS-DRG Percutaneous cardiovascular procedure w/o coronary artery stent w/o MCC Applicable NCD/LCD: NCD 20.7 CERT error findings: 100 percent met the NCD criteria for the procedure, but the admission was not reasonable and necessary for an inpatient level of care. First Coast denial rate for July-September 2012: 39 percent Percentage of review: Initially 30%, increased to 60% effective July 19, Date prepayment implemented: January 1, 2012 Other MACs are also beginning to implement prepayment review of select MS-DRGs IMPACT 46 IMPACT

24 Definition of an Inpatient Physicians should order admission for patients who are expected to need hospital care for 24 hours or more, and treat other patients on an outpatient basis. However, admissions of particular patients are not covered or noncovered solely on the basis of the length of time the patient actually spends in the hospital. The decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors: The patient s medical history and the severity of the signs and symptoms which impact the medical needs of the patient and influence the expected length of stay (LOS). The medical predictability of something adverse happening to the patient; The need for diagnostic studies that appropriately are outpatient services and the availability of diagnostic procedures at the time when and at the location where the patient presents. (Source: Medicare Benefit Policy Manual, Chapter 1, Section 10) 2012 IMPACT 47 Definition of an Inpatient Potential for expansion to other services / providers. Several MACs performing pre-payment DRG review are linking Part A and B claims, and subsequently recouping Part B physician reimbursements if the admission is denied Medicare Appeals Council finding -- concluding that CMS should offset or otherwise credit the hospital for the medically necessary outpatient and observation services if inpatient admission is denied by the RAC as not medically necessary. [Reference: Medicare Benefit Policy; Manual, (CMS Pub ); Chapter 6, 10.] For 2012, CMS has initiated a demonstration project permitting selected hospitals to resubmit claims for services denied for inpatient as an outpatient claim IMPACT 48 IMPACT

25 RAC Audit Readiness RAC Preparation Identify a point person / team Stay up to date by reviewing the RAC website frequently Implement procedures to promptly respond to RAC requests and to effectively track records submissions and RAC responses Develop procedures to monitor RAC findings and file appeal before 120 deadline when appropriate Determine any corrective actions to be taken Conduct an internal assessment to ensure that submitted claims meet Medicare rules Review documentation and processes for appropriateness While RAC reviews Medicare Part A & B only, other entities will also audit records so setting up appropriate practices will minimize issues and downtime over the long run 2012 IMPACT 49 RACTrac Data Healthcare providers have only appealed about one third of RAC denials, even though most appeals are successful Region A Region B Region C Region D Nationwide % of Denials Appealed % of Appealed Denials Overturned 2012 IMPACT 50 IMPACT

26 Why Did We Not Appeal? 1. Agree with the RAC determination 2. Do not agree with the RAC determination but are unable to meet the appeal deadline 3. Do not agree with the RAC determination but do not have staff and resources to appeal 4. Do not agree with the RAC determination, but do not have expertise in appeals 5. Do not agree with the RAC determination but it is too expensive to appeal 6. Other 2012 IMPACT 51 Coding and Documentation Improvement Proper coding and everything which flows from it - is based upon documentation in the medical record. Therefore, the record should: þ Capture a concise and specific description of services. þ Implement a standard dictation format to ensure complete data capture. þ Strive for clinical clarity for accurate procedure and diagnosis code selection. þ Ensure all records are: Legible, dated, timed, signed, and timely Consistent and without internal contradictory statements þ Recognize the EP lab procedure log as supportive procedure information only. The physician s dictation ultimately determines the ability to assign codes. þ Maintain policy that no changes are made to documentation unless approved by the physician IMPACT 52 IMPACT

27 Tips for Coding and Billing Make sure key elements are included in the case documentation Provide clear description of all techniques used: Specify 3-D mapping when used Transseptal puncture, if performed Ultrasound, including key terms for TEE or ICE Ablation site(s), energy source, and results Document clinical indications to level of specificity appropriate to procedure: paroxysmal AF refractory to medication management ischemic dilated cardiomyopathy (IDCM), documented prior MI, NYHA Class II and III heart failure, and measured LVEF < 35% 1 Clinical documentation improvements support accurate capture of all appropriate charges and codes. Identify all pacing and recording sites in body of report State specific services when less than a comprehensive study is performed Include all diagnoses, both primary and secondary (co-morbid conditions) 1 Medicare NCD for Implantable Automatic Defibrillators (20.4) THERMOCOOL Naviga@on Catheters are approved for drug refractory recurrent symptoma@c paroxysmal atrial fibrilla@on, when used with CARTO Systems (excluding NAVISTAR RMT THERMOCOOL Catheter) IMPACT 53 Tips for Coding and Billing Invest in Your Staff Meet with the hospital's coders and billers regularly Explain EP terminology and procedures or invite the coders to observe a procedure Keep the staff, coders and billers abreast of these new techniques and technologies Make sure the charge description master is current and accurate Involve physicians when designing the operative report and other clinical and data capture documents Regular auditing - before or after coding - can help to improve accuracy Coders may cover multiple specialties continuous advances in technology and techniques make it difficult to keep up. Better understanding of terms improves billing accuracy IMPACT 54 IMPACT

28 Coding and Documentation Improvement Health care is increasingly data driven Cross functional skill sets support evolving activities Enhanced roles of HIM and Coding Department staff in quality of information Maintain open lines of communication between clinicians and coding staff Education is the key Work Smart 2012 IMPACT 55 Questions? 2012 IMPACT 56 IMPACT

29 Provider Education and Reimbursement Resources 2012 IMPACT 57 Coding and Reimbursement Resources Reimbursement and Coding Guide for facilities and physicians Reimbursement Hotline: Trained coding experts available 8 am to 5 pm CT, Monday thru Friday and will respond within one business day Online C-Code Finder to find HCPCS codes THERMOCOOL Naviga@on Catheters are approved for drug refractory recurrent symptoma@c paroxysmal atrial fibrilla@on, when used with CARTO Systems (excluding NAVISTAR RMT THERMOCOOL Catheter) IMPACT 58 IMPACT

30 Learning Objectives 1. Identify tools that promote a timely, effective reimbursement process. 2. Communicate techniques that support accurate coding and documentation. 3. Review current process; consider appropriate updates to enhance efficiency and compliance. Who Should Participate EP Clinical, Administrative and Reimbursement Teams: Physicians, department managers, nurses and all clinical roles; staff holding roles in coding, CDM, revenue cycle, HIM; audit, compliance, revenue integrity; EP practice clinical and reimbursement staff. Course Summary EP specialists seek to maintain a strong educational baseline in coding, documentation and reimbursement compliance. This session offers a discussion of hot topics. Expanded discussion of cardiovascular RAC audit issues, including the prepayment review demonstration, admissions criteria, documentation improvement and charge capture challenges. Features and Highlights EP coverage and reimbursement issues, including transseptal status RAC prepayment review, tips for overall audit readiness and proactive response Vignettes: EP studies and ablation, device implants, with focus on related charge capture challenges Identifying and resolving common coding pitfalls and oversights, appropriate use of modifiers Clinical documentation as the driver in correct code selection Status of ICD-10-CM and ICD-10-PCS and implementation preparedness Emphasis on accuracy, timeliness, efficiency and process improvement Interactive practical discussion, sub-specialty focused, team oriented learning Faculty Sheila Sylvan, CCS-P, CPC-I, IMPACT, Marietta, GA Questions Welcomed in Advance Post-Conference Q&A Live and Detailed PowerPoint Learning Guide Questions Laura Driscoll LDriscoll@impactmed.com x226 * THERMOCOOL Navigation Catheters are approved for drug refractory recurrent symptomatic paroxysmal atrial fibrillation, when used with CARTO Systems (excluding NAVISTAR RMT THERMOCOOL Catheter) Biosense Webster, Inc XXXX Hosted by Biosense Webster, Inc. Complimentary Registration Coding Changes and Compliance Update for Electrophysiology Services Coding and Reimbursement Resources EP Procedure Documentation Best Practices Electrophysiology Services Coding Checklist EP Coding and Reimbursement Frequently Asked Questions THERMOCOOL Naviga@on Catheters are approved for drug refractory recurrent symptoma@c paroxysmal atrial fibrilla@on, when used with CARTO Systems (excluding NAVISTAR RMT THERMOCOOL Catheter) IMPACT 59 Coding and Reimbursement Provider Education Comprehensive overview of coding and billing for EP catheter ablation: Join for this semi-annual update! us Webinar / Audio Conference Thursday, June 7, PM PST / 4-5PM EST Hot Topics in Electrophysiology, Coding and Compliance Comprehensive, Convenient Team-Learning Opportunity! Live Coding Audio Conferences: Recorded audio sessions available on-line at afiballiance.com Live Seminars: Half-day coding and billing seminars co-sponsored with Cordis THERMOCOOL Naviga@on Catheters are approved for drug refractory recurrent symptoma@c paroxysmal atrial fibrilla@on, when used with CARTO Systems (excluding NAVISTAR RMT THERMOCOOL Catheter) IMPACT 60 IMPACT

31 Thank You for Participating! presented by Sheila Sylvan Hosted by 2012 IMPACT 61 IMPACT