Advanced Electrophysiology Coding

Advanced Electrophysiology Coding May 2008

Notices Current Procedural Terminology (CPT ) is copyright 2007 American Medical Association. All Rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. CPT is a trademark of the American Medical Association. Medtronic does not currently offer an FDA-approved product for catheter ablation services described by CPT 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]. These coding suggestions and coverage guidelines do not replace seeking coding advice from the payer and/or your coding staff. The ultimate responsibility for correct coding lies with the provider of services. Please contact your local payer for interpretation of the appropriate codes to use for specific procedures. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other third party payers as to the correct form of billing or the amount that will be paid to providers of service. 2

CEUs for Coders A survey will be sent out to all participants a few days after the session. This survey will include information on CEU certificates. AAPC This program has the prior approval of the American Academy of Professional Coders (AAPC) for one continuing education hour. Granting of prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor. AAPC Index# MT0407081201A AHIMA This program has been approved for 1 continuing education unit for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). 3

Topics Quick Coding Overview Quick Procedural Overview Diagnostic Electrophysiology Intracardiac Catheter Ablation Cardiac Rhythm Devices Appendix: Composite APCs 4

Quick Coding Overview Physicians use CPT to report all services. Hospitals use CPT codes to report outpatient claims. This is mandated under HIPAA. Although CPT codes themselves are standardized, there are multiple credible sources for guidance in how codes are assigned and used. Proper CPT code assignment involves identifying applicable directives and balancing them against each other. 5

Sources for Coding Guidance Credible sources for coding guidance include the AMA, AHA, medical specialty societies, and CMS. American Medical Association CPT Assistant This monthly coding journal is published by the AMA and contains articles on code usage and coding Q&As. CPT Changes: An Insider s View This annual reference contains vignettes and directions for new codes. American Hospital Association Coding Clinic for ICD-9-CM Published quarterly by AHA, this contains with guidelines for diagnosis coding. Content is approved by AHA, CMS, National Center for Health Statistics, and American Health Information Management Association. 6

Sources for Coding Guidance Medical Specialty Societies Coding Guide for Heart Rhythm Procedures and Services The Heart Rhythm Society publishes this guide. Practical Reporting of CV Services and Procedures The American College of Cardiology publishes this coding guide. CMS (and other payors) National Correct Coding Initiative NCCI is a set of over 100,000 coding edits accompanied by a 12- chapter coding policy manual. It is maintained by CMS. Payor Medical Policy Medicare contractors, as well as commercial payors, often include directives on code usage in their medical policies. 7

How Important is Code Accuracy? Misrepresenting codes is a felony. So is helping or encouraging others to submit inaccurate codes. any person who engages in a pattern or practice of presenting or causing to be presented a claim for an item or service that is based on a code that the person knows or should know will result in a greater payment to the person than the code the person knows or should know is applicable to the item or service actually provided. shall be subject to a civil money penalty of not more than $10,000 for each item an assessment of not more than 3 times the amount claimed for each such item guilty of a felony and upon conviction fined not more than $25,000 or imprisoned for not more than 5 years, or both. Title 42 of the US Code (Section 1320a-7a) (Section 1320a-7b) http://www.ssa.gov/op_home/ssact/title11/1128a.htm 8

Quick Procedural Overview Electrophysiology services involve the electrical function of the heart. This contrasts with structural heart issues, such as clogged coronary arteries or faulty valves. Electrical issues are diagnosed and treated by electrophysiologists and cardiologists. 9

Diagnostic Electrophysiology Diagnostic catheters are inserted percutaneously and then threaded through the vena cava into the heart. They are positioned at key locations for pacing and recording, often with mapping. This identifies the nature, causes and pathways of arrhythmias. Diagnostic electrophysiology is coded to the Medicine section of CPT, 93600 to 93631 and 93660 to 93662. 10

Therapeutic Electrophysiology Electrophysiologic procedures correct arrhythmias by destroying the aberrant tissue or disrupting the circuit. Ablation is most commonly performed for supraventricular (ie. atrial) arrhythmias, such as: atrial fibrillation atrial flutter supraventricular tachycardia Wolff-Parkinson-White Ablation can also be performed for the more deadly ventricular tachycardias. 11

Therapeutic Approaches Destruction or disruption of heart tissue can be performed by several approaches. Operative ablation is performed via an open or thoracoscopic approach on an inpatient basis. These procedures are coded to the Surgery section of CPT, 33250 to 33266. Transcatheter ablation is performed via percutaneous puncture, in the inpatient or outpatient setting at the physician s determination. These procedures are coded in the Medicine section of CPT, 93650 to 93562. 12

Cardiac Rhythm Devices Some patients are not candidates for ablations. Also, some arrhythmias are not amenable to ablation. In these situations, the arrhythmias can often be chronically controlled by implantable cardiac rhythm devices, such as pacemakers. Device implantation is coded to the Surgery section of CPT, 33202 to 33249. Device testing is coded to the Medicine section of CPT, 93640 to 93642 and 93724 to 93744. 13

Diagnostic Electrophysiology 14

Diagnostic EP Study In a diagnostic EP study, catheters are threaded through the vena cava and into the heart. Typically, two or more catheters are used and are most commonly positioned at: Right atrium (HRA) bundle of HIS (HBE) Right ventricle (RVA, RVOT) Catheters are also sometimes positioned at: Left atrium, or in the overlying coronary sinus (CS) Left ventricle 15

Diagnostic Steps Electrophysiologists used the catheters to perform one or more steps to diagnose the arrhythmia and its circuits: Pacing The catheter stimulates the sites to assess their response in conducting the signal. There are multiple pacing protocols. Recording An EKG is recorded from the site for analysis of the arrhythmia. Mapping Mapping localizes the precise site of the arrhythmia s origin. Induction of arrhythmia Stimulation protocols are used to attempt to reproduce and then terminate the arrhythmia to verify its mechanisms. 16

Comprehensive EP Study Coding CPT has two basic codes for comprehensive EP studies, along with two add-on codes. 93619 Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted induction of arrhythmia 93620 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia, with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning 93621 with left atrial pacing and recording from coronary sinus or left atrium 93622 with left ventricular pacing and recording 17

Other Add-On Codes Mapping 93609 Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia 93613 Intracardiac electrophysiologic 3-dimensional mapping The mapping codes can only be submitted with study code 93620. Also, only one mapping code is assigned per study. Programmed Stimulation 93623 Programmed stimulation and pacing after intravenous drug infusion In some cases, an intravenous drug is infused as a diagnostic measure to induce the arrhythmia, particularly if other protocols are unsuccessful. CPT Assistant, April 2004, p.9-10 18

Component EP Study Coding Individual codes for each component of electrophysiology studies are also available. 93600 Bundle of HIS recording 93602 Intra-atrial recording 93603 Right ventricular recording 93610 Intra-atrial pacing 93612 Intraventricular pacing 93618 Induction of arrhythmia by electrical pacing Comprehensive code 93619 includes all the services in component codes 93600 to 93612. Comprehensive code 93620 also includes all of these components, plus 93618. ACC Coding Guide 2007, p.3.28 19

Diagnostic EPS Physician Hospital outpatient Issue : Single Catheter Studies Can the comprehensive study codes 93619 and 93620 be used when the study is performed using a single catheter? Coding Comment No. Assign the appropriate component codes 93600 to 93618 instead when the study is performed via a single catheter. Discussion Codes 93619 and 93620 are specifically defined and intended for multiple catheters. CPT Assistant, Summer 1994, p.14-15, April 2004, p.9-10 20

Diagnostic EPS Physician Hospital outpatient Issue : EP Study without RA, HBE, or RV Can the comprehensive study codes 93619 and 93620 be used when the right atrium, right ventricle or bundle of HIS are omitted? Coding Comment No. Assign the appropriate component codes 93600 to 93618 instead when the study omits the RA, RV or bundle of HIS. Discussion Codes 93619 and 93620 are specifically defined and intended for pacing and recording from all three sites. CPT Assistant, Summer 1994, p.14-15, April 2004, p.9-10 21

Diagnostic EPS Physician Hospital outpatient Issue : Atrial only study Some arrhythmias are known to be atrial only phenomena so rather than a comprehensive EP study, only atrial pacing and recording are performed. How is this coded? Coding Comment Assign component codes 93602 for recording and 93610 for pacing. Discussion Code 93602 is NCCI-edited with ablation code 93651 but an override is permitted with 59 for a true diagnostic study. 22

Diagnostic EPS Physician Hospital outpatient Issue : CS catheter without comprehensive study When a coronary sinus catheter is placed for left atrial recording and pacing during an atrial only study, how is this coded? Coding Comment Assign component codes 93602 and 93610. If 93602 and 93610 have already been assigned for right atrial study, no additional code is assigned for the left atrial study. Discussion Per CPT manual notes, add-on code +93621 for left atrial study from the coronary sinus can only be assigned in conjunction with the comprehensive EP study code 93620. CPT Assistant, April 2004, p.9-10 ACC Coding Guide 2007, p.3.29 23

Diagnostic EPS Physician Hospital outpatient Issue : Use of fluoroscopy during diagnostic EP study Can the use of fluoroscopy be coded separately with a diagnostic EP study? If yes, what code is used? Coding Comment Do not assign a separate code for use of fluoroscopy. Discussion NCCI edits prohibit 76000 with the diagnostic EP study codes. NCCI policy explicitly states that fluoroscopic guidance is integral and fluoroscopy codes are not separately reportable with the procedures described by 93600 93662. A modifier override is permitted only in unique circumstances. NCCI Policy Manual, Version 13.3, Chapter 11, I.-2 and I-9 24

Diagnostic EPS Physician Hospital outpatient Issue : Agents used with programmed stimulation What drugs are typically infused for programmed stimulation +93623? Coding Comment The most common is Isuprel (isoproterenol). Other drugs include procainamide, epinephrine and atropine. Discussion Although hospitals may include charges for these drugs on their bills, there is no separate payment under OPPS. Code +93623 is an add-on and is assigned only in conjunction with the comprehensive EP study codes 93619 and 93620. HRS Coding Guide 2007, p.26, 27, 30, 34 ACC Coding Guide, p.3.29 25

Diagnostic EPS Physician Hospital outpatient Issue : Diagnostic EP Study with Ablation Can a diagnostic EP study be coded separately with an ablation? Coding Comment Yes, usually. An initial diagnostic study prior to ablation during the same operative episode is coded separately. However, do not code a diagnostic study separately when a previous diagnostic study was performed, unless a specific medical reason exists to repeat it. Discussion Per CPT manual notes, diagnostic study is separately codable. Several NCCI policies allow reporting an initial diagnostic study, but prohibit reporting a duplicate study with the intervention. HRS Coding Guide 2007, p.31 NCCI Policy Manual, Version 13.3, Chapter 9, D and Chapter 1, B (Surgical) 2 26

Intracardiac Catheter Ablation 27

Ablation Coding There are three CPT codes for EP ablation, depending on the site of tissue destruction. 93650 Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement 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 93652 for treatment of ventricular tachycardia Medtronic does not currently offer an FDA-approved product for catheter ablation services described by CPT 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]. 28

Other Related Codes Follow-Up Study 93624 Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy including induction or attempted induction of arrhythmia Intracardiac Echocardiography (ICE) 93662 Intracardiac echocardiography during therapeutic/diagnostic intervention ICE is often used with transseptal puncture to access the left atrium or left ventricle, for both diagnostic EP studies and for ablations. It allows real-time visualization of anatomy and catheter position during puncture. 29

Catheter Ablation Physician Hospital outpatient Issue : Use of 93650 What ablation sites and arrhythmias are coded with 93650? Coding Comment Code 93650 is for ablation of the AV node. Destruction of the AV node is commonly performed for intractable atrial fibrillation. Use of a temporary pacemaker is not coded separately. Concurrent insertion of a permanent pacemaker is coded separately. Discussion Because the procedure intentionally creates a complete heart block, these patients require permanent pacemaker implantation. ACC Coding Guide 2007, p.3.32 30

Catheter Ablation Physician Hospital outpatient Issue : Use of 93651 What ablation sites and arrhythmias are coded with 93651? Coding Comment Code 93651 is used for destruction of all supraventricular, (ie. atrial) foci, circuits and accessory pathways, including those at the cavotricuspid isthmus and around the mitral valve. Arrhythmias for which this is performed include atrial fibrillation, atrial flutter, WPW and other supraventricular tachycardias. Mapping can be coded separately. Discussion Code 93651 is used once regardless of the number of foci destroyed or ablation lines created. ACC Coding Guide 2007, p.3.32 HRS Coding Guide, p.33 31

Catheter Ablation Physician Hospital outpatient Issue : Pulmonary vein isolation In pulmonary vein isolation for atrial fibrillation, ablation lines are created around the openings of the pulmonary veins in the left atrium. What code is used for pulmonary vein isolation? Coding Comment Code 93651 is an option but payor requirements must be verified. Discussion Although the medical specialty societies recommend 93651, as do some payors (eg. Cigna), medical policy for other payors (eg. Regence, Wellmark) requires 93799. ACC Coding Guide 2007, p.3.32 HRS Coding Guide, p.34 Regence Medical Policy No.138 Wellmark Medical Policy 02.02.04 Cigna Coverage Position No. 0469 32

Catheter Ablation Physician Hospital outpatient Issue : Follow-up study with ablation Can code 93624 be used with ablation codes to show the steps taken for immediate confirmation of the ablation s success? Coding Comment No. Code 93624 is reserved for follow-up studies performed at a separate session to test the effectiveness of chronic therapy. Discussion This issue has not been specifically addressed by the AMA or medical specialty societies. NCCI edits prohibit 93624 with any of the ablation codes. Articles from several carriers state that 93624 is used for assessment on subsequent days following ablation. HealthNow, A34524 Group Health, A18005 33

Catheter Ablation Physician Hospital outpatient Issue : Post-ablation programmed stimulation Can code +93623 be used if an agent is infused for programmed stimulation immediately after ablation to confirm its success? Coding Comment Yes, but only if a comprehensive diagnostic EP study was also performed during the same session. If a comprehensive diagnostic EP study was not performed, no code is assigned for the post-ablation programmed stimulation. Discussion Code +93623 is an add-on and can be assigned only with the comprehensive EP study codes 93619 and 93620. NCCI edits do not prohibit +93623 with any of the ablation codes. CPT Assistant, December 2007, p.16 HRS Coding Guide, p.30, 31 ACC Coding Guide 2007, p.3.30 34

Catheter Ablation Physician Hospital outpatient Issue : Transseptal puncture Can cardiac catheterization code 93527 be used when a transseptal puncture is performed to access the heart s left side? Coding Comment It s suggested that 93527 not be assigned unless all components of a cardiac catheterization take place, including hemodynamics. Absent a full scale cardiac catheterization, physicians may consider using 22 to show the additional work but hospitals have no other options to show transseptal puncture. Discussion Although ACC advocates use of 93527 for transseptal punctures, HRS advises use of 93527 only with a full scale cardiac cath. HRS Coding Guide, p.32, 34 ACC Coding Guide 2007, p.3.32 35

Catheter Ablation Physician Hospital outpatient Issue : ICE during transseptal puncture Can the use of intracardiac echocardiography during transseptal puncture be coded? Coding Comment Assign +93662 when transseptal puncture is performed using intracardiac echocardiography. Discussion Per CPT manual notes, code +93662 can be used with ablation codes 93651 and 93652 (as well as with left-sided diagnostic EP study codes +93621 and +93622). HRS Coding Guide, p.32, 34 ACC Coding Guide 2007, p.3.33 36

Cardiac Rhythm Devices 37

Cardiac Rhythm Device Types There are four key rhythm devices. They are implanted for different diagnostic indications: Pacemakers (PPMs) for bradycardia Bi-Ventricular Pacemakers (BiV-PPM, CRT-P) for heart failure, with or without bradycardia Defibrillators (ICDs) for ventricular tachycardia, fibrillation, or SCD Bi-Ventricular Defibrillators (BiV-ICD, CRT-D) for the combination of ventricular tachycardia/ fibrillation/scd and heart failure http://www.fda.gov/cdrh/pdf/p010015a.pdf http://www.fda.gov/cdrh/pdf/p010031b.pdf * Per NCD Manual,section 20.4, conventional defibrillators may also be implanted for other indications including heart failure and cardiomyopathy (SCD-HeFT and COMPANION criteria). 38

Pacemaker Coding The most common pacemaker codes include: 33206 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial 33207 ventricular 33208 atrial and ventricular 33212 Insertion or replacement of pacemaker pulse generator only; single chamber 33213 dual chamber 33222 Revision or relocation of skin pocket for pacemaker 33233 Removal of permanent pacemaker pulse generator 39

Defibrillator Coding The most common defibrillator codes include: 33223 Revision or relocation of skin pocket for cardioverterdefibrillator 33240 Insertion of single or dual chamber pacing cardioverterdefibrillator pulse generator 33241 Subcutaneous removal of single or dual chamber pacing cardioverter-defibrillator pulse generator 33249 Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator 40

Defibrillator G Codes Hospitals had been required to use HCPCS II G codes for defibrillators. These codes have been deleted for 2008. Hospitals should now use the regular CPT codes instead. Deleted G Code G0297 G0298 G0299 G0300 Brief Description Insertion, single chamber defibrillator generator Insertion, dual chamber defibrillator generator Insertion of lead and single chamber defibrillator generator Insertion of leads and dual chamber defibrillator generator CPT Code Brief Description 33240 Insertion of single or dual chamber defibrillator generator 33249 Insertion of lead(s) for single or dual chamber defibrillator and insertion of generator CMS decided the difference in cost between single and dual chamber devices wasn t worth the trouble of tracking. Federal Register, November 27, 2007, p.66702 41

Use of Fluoroscopy Fluoroscopy is used to guide and confirm placement of transvenous leads. This is coded separately. 71090 Insertion pacemaker, fluoroscopy and radiography Though its definition uses the term pacemaker only, code 71090 is intended to be assigned with insertion of both pacemakers and defibrillators. Example: Pacemaker 33208 Insertion of pacemaker with transvenous electrodes, atrial and ventricular 71090 Pacemaker fluoroscopy Example: Defibrillator 33249 Insertion of leads for cardioverter-defibrillator and insertion of pulse generator 71090 Pacemaker fluoroscopy CPT Assistant, August 2002, p.11 42

Bi-Ventricular Devices What differentiates biventricular devices from conventional ones is the left ventricular lead. All cardiac rhythm devices have leads on the heart s right side, either the right atrium (RA), or the right ventricle (RV), or both. But only bi-ventricular devices have a lead at the left ventricle (LV) as well. 43

Bi-Ventricular Coding Bi-ventricular pacemakers and defibrillators use the same codes as conventional pacemakers and defibrillators. The left ventricular lead is then shown with an add-on code. 33225 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of defibrillator or pacemaker pulse generator Example: Bi-V Pacemaker 33208 Insertion of pacemaker with transvenous electrodes, atrial and ventricular 33225 Insertion of LV lead 71090 Pacemaker fluoroscopy Example: Bi-V Defibrillator 33249 Insertion of leads for cardioverter-defibrillator and insertion of pulse generator 33225 Insertion of LV lead 71090 Pacemaker fluoroscopy 44

Device Testing and Follow-Up Both pacemakers and defibrillators need to be checked periodically. This can be done for either device via NIPS or interrogation. The difference is that for NIPS, an arrhythmia is induced and for an interrogation, it is not. NIPS - With Induction of Arrhythmia a programmer instructs the previously implanted device, via telemetry, to induce and then terminate an arrhythmia performed to verify device status, reassess the pacing or shock level needed and identify if reprogramming is needed must be performed in a specially equipped suite Interrogation - Without Induction of Arrhythmia device is checked for battery status and settings stored data on events is downloaded for clinical analysis can be done in the office because no arrhythmia is induced 45

Pacemaker Testing Codes NIPS (With Induction of Arrhythmia) 93724 Electronic analysis of antitachycardia pacemaker system (includes electrocardiographic recording, programming of device, induction and termination of tachycardia via implanted pacemaker and interpretation of recordings) This code was designed for pacemakers directed at tachycardia, as opposed to bradycardia. These devices are not commonly used today because supraventricular tachycardia is usually treated through other means. However, code 93724 has been retained for use in other scenarios. CPT Assistant, Summer 1994, p.23 ACC CPT Guide 2007, p.3.34 46

Pacemaker Testing Codes Interrogation (Without Induction of Arrhythmia) 93731 Electronic analysis of dual-chamber pacemaker system, without reprogramming 93732 with reprogramming 93734 Electronic analysis of single-chamber pacemaker system, without reprogramming 93735 with reprogramming Pacemakers are interrogated periodically after implantation to verify proper functioning. By definition, these codes include evaluation of programmable parameters, recordings and interpretation, and analysis of event markers with device response. 47

Defibrillator Testing Codes NIPS (With Induction of Arrhythmia) 93640 EP evaluation of defibrillator, including DFT evaluation and arrhythmia induction and termination, at time of initial implantation or replacement 93641 with testing of defibrillator pulse generator 93642 EP evaluation of defibrillator, including DFT evaluation and arrhythmia induction and termination, and reprogramming Unlike pacemakers, defibrillators are typically tested immediately after implantation. They also continue to be tested on periodic basis afterwards. Example: Bi-V Defibrillator 33249 Insertion of leads for defibrillator and insertion of pulse generator 33225 Insertion of LV lead 71090 Pacemaker fluoroscopy 93641 Device eval w induction 48

Defibrillator Testing Codes Interrogation (Without Induction of Arrhythmia) 93741 Electronic analysis of cardioverter-defibrillator, single chamber without reprogramming 93742 with reprogramming 93743 Electronic analysis of cardioverter-defibrillator, dual chamber, without reprogramming 93744 with reprogramming Defibrillators are also interrogated periodically after implantation, without induction. By definition, these codes include evaluation of programmable parameters, recordings and interpretation, and analysis of event markers with device response. 49

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Defibrillator testing at implantation Defibrillator leads and generators are typically tested with arrhythmia induction at the end of the implantation operative episode. How is this coded? Can interrogation codes be used? Coding Comment Assign 93641, in addition to the device implantation codes. Do not assign interrogation codes 93741 93744 separately. Discussion According to CPT manual notes, codes 93741 93744 are assigned only for subsequent episodes of care. When testing is performed, be sure to assign 93641 with both implantation and replacement of a generator. 50

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Codes for defibrillator testing at implantation What s the difference between 93640 and 93641? Which code is most commonly used? Coding Comment Most scenarios for ICD testing at implantation use 93641. Code 93641 is used for testing leads via an implanted generator. Code 93640 is for testing leads via an external generator. Discussion Current defibrillator generators are almost always capable of self-testing, eliminating the need for testing via connection to an external device. ACC CPT Guide 2007, p.3.30-3.31 CPT Assistant, Summer 1994, p.22 51

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Testing with new lead placement only After capping an existing lead, a new lead is inserted and connected to the previously implanted generator. Is 93640 or 93641 assigned for testing the newly implanted lead? Coding Comment It s suggested that 93641 be assigned. Discussion The scenario has not been specifically addressed in references. The leads are still being tested via an implanted generator, albeit a previously implanted one. By its nature, lead testing also tests generator function. 52

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Pacemaker testing/programming at implantation Pacemakers leads are tested and the generator is programmed at the end of the implantation operative episode. How is this coded? Coding Comment It isn t. Do not assign additional codes for pacemaker testing or programming at the time of implantation. Discussion It is inappropriate to report the service of initial programming of pacemakers at the time of implantation. Codes 93731 93735 are assigned only for subsequent episodes. ACC CPT Guide 2007, p.4.29 53

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Generator change-out procedure What procedure codes are used for replacing a previously implanted pacemaker or defibrillator generator? Coding Comment Assign 33212 33213 for insertion of the new pacemaker generator, or 33240 for the new defibrillator generator. Assign a separate code for removal of the old generator, 33233 for pacemaker or 33241 for defibrillator. Do not code revision of the pocket separately. Discussion Codes for removal of the old generator are not NCCI-edited. Remember to add 93641 for defibrillator testing when performed. CPT Assistant, June 1996, p.10 and October 1996, p.10 54

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Generator change-out diagnosis What diagnosis codes are used for replacing a previously implanted pacemaker or defibrillator generator? Coding Comment For routine end-of-life, use V53.31 for pacemaker replacement and V53.32 for defibrillator replacement. For mechanical complications or recall, use 996.01 for pacemaker or 996.04 for defibrillator. Discussion Can secondary diagnosis codes also be assigned for the underlying conditions for which the device was initially implanted? Coding Clinic, 3 rd Q 1992, p.3, and 2 nd Q 2005, p.3 55

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Upgrade from PPM to ICD procedure What procedure codes are used for upgrading a PPM to an ICD? Coding Comment Assign 33240 for the new ICD generator if the leads are re-used. Assign 33249 for ICD generator and leads if one or more new leads are placed in the RA or RV. Add +33225 for the LV lead if the upgrade is to a BiV-ICD. Code removal of the PPM generator separately with 33233. Do not code revision of the pocket separately. Discussion Codes for removal of the old generator are not NCCI-edited. Remember to add 93641 for defibrillator testing when performed. CPT Assistant, Special 2006, p.3 56

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Upgrade from PPM to ICD diagnosis What diagnosis codes are used for upgrading a PPM to an ICD? Coding Comment Assign the diagnosis code that represents the clinical reason for the upgrade, eg. congestive heart failure 428.0, cardiomyopathy 425.4, or ventricular tachycardia 427.1. Discussion V codes are not appropriate because treatment is being directed at a current disease process. Coding Clinic, 3 rd Q 2005, p.8-9, and 1 st Q 2007, p.20 57

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Pocket revision with generator change-out Replacement of a pacemaker or defibrillator generator often involves revising the pocket to accommodate the new generator, especially in an upgrade. Is this coded separately? Coding Comment In most circumstances, don t code pocket revision separately. Discussion Code 33222 for PPM pocket revision is NCCI-edited with 33212 (PPM generator insertion) and 33233 (PPM generator removal). Code 33223 for ICD pocket revision is NCCI-edited with 33240 (ICD generator insertion) and 33241 (ICD generator removal). Insertion of a generator always includes forming the pocket. NCCI edits, 1 st Q 2008, Column 1/Column 2, Mutually Exclusive 58

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Pocket revision with other procedures Pocket revision is sometimes performed with other pacemaker and defibrillator procedures, such as lead revision. Is pocket revision separately codable with these procedures? Coding Comment A significant pocket revision can be coded separately. Discussion No NCCI edits prevent coding 33222 or 33223 separately with procedures other than generator insertion and removal. Keep in mind that the pocket revision codes are valued to include 90 minutes or more of physician intra-service time NCCI edits, 1 st Q 2008, Column 1/Column 2, Mutually Exclusive 59

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Coronary sinus venography with LV lead Insertion of a left ventricular lead for a biventricular device requires injection of contrast and venography of the coronary sinus. Can this be coded separately? Coding Comment Coronary sinus venography is not coded separately. Discussion The vignette for +33225 describes coronary sinus venography. Services described in code vignettes are considered integral to the procedure unless identified as separately coded. CPT Changes: An Insider s View 2003, p.74 60

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Failed transvenous insertion of LV lead Following generator and RA/RV lead insertion, transvenous insertion of a left ventricular lead is attempted but cannot be completed. Can this be coded and billed? Coding Comment The attempted procedure can be coded and billed. Physicians assign +33225 53 for a discontinued procedure. Hospitals assign +33225 74 for a procedure discontinued after administration of anesthesia. Discussion All physician claims submitted with 53 are subject to individual review and pricing. Hospitals are paid the regular APC rate for the procedure. 61

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Sub-Q-Array code How is implantation of a Sub-Q-Array coded? This adjunctive electrode is implanted in the subcutaneous tissue of the chest for patients with high DFTs for whom standard leads are insufficient. Coding Comment Use of unlisted code 33999 is suggested. Discussion Current defibrillator lead codes are intended for implantation of the lead within heart tissue. HRS suggests that some payors may accept 33217 instead. HRS also recommends confirming payor requirements prior to claim submission. HRS Coding Guide 2007, p.48 62

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Dual chamber pacemaker with one lead The patient has an existing pacemaker generator and two leads. The generator is replaced. One lead is re-used but the other is capped and new lead is inserted. How is this coded? Coding Comment Use code 33206 or 33207 for single atrial or ventricular lead. Discussion The work involved for one lead is analogous to 33206 or 33207, not 33208. CMS device edits allow hospitals to use 33206 and 33207 with device codes C1785 and C2619 for dual chamber pacemakers. Hospitals must also remember to add C1898 for the lead. HRS Coding Guide 2007, p.40 63

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Dual chamber defibrillator with one lead The patient has an existing defibrillator generator and two leads. The generator is replaced. One lead is re-used but the other is capped and new lead is inserted. How is this coded? Coding Comment Use 33249. Discussion Code 33249 is defined for one or more electrodes as well as for single or dual chamber generators. CMS device edits allow hospitals to use 33249 with device code C1721 for dual chamber defibrillators. HRS Coding Guide 2007, p.45 64

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : One new lead for existing dual chamber device The patient has an existing dual chamber PPM or ICD generator with two leads. One lead is capped and a new one inserted, leaving the other lead and generator in place. How is this coded? Coding Comment Use of 33216 is suggested. Discussion The work is analogous to 33216 for lead with single chamber. CMS device edits allow hospitals to use 33216 with device codes C1779 for single pacemaker lead and C1777 for single defibrillator lead. HRS Coding Guide 2007, p.43 65

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Removal of generator to reposition lead To access and reposition an existing lead, the generator must sometimes be removed and then reinserted. How is this coded? Coding Comment Use 33215 for lead repositioning. Do not code generator removal and reinsertion separately. Discussion Lead revision includes removing and reinserting the generator. Steps performed for access are typically not coded separately. Hospitals must not assign any generator implantation code, eg. 33240, because they are valued to include the cost of the device. HRS Coding Guide 2007, p.42 ACC CPT Guide 2007, p.4.30 66

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Removal and reinsertion of same lead The lead was removed with the intention of replacing it. However, it was tested and found to be satisfactory so it was reinserted. How is this coded? Coding Comment Use of 33215 for lead repositioning is suggested. Discussion The scenario has not been specifically addressed in references. The work involved is analogous to lead repositioning. Evaluation of thresholds is integral and not separately coded. Hospitals must not assign any lead implantation code, eg. 33216, because these are valued to include the cost of the device. 67

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Screw set repair The lead is loose where it meets the generator, so the pocket is opened and the connection is tightened. How is this coded? Coding Comment Use of 33218 or 33220 for lead repair is suggested. If fluoroscopy is used, do not assign 76000 or 76001 separately. Do not code generator removal and reinsertion separately. Discussion The scenario has not been specifically addressed in references. The work involved is analogous to lead repair. NCCI policy explicitly states that fluoroscopy codes are not separately reportable with 33202 33249 NCCI Policy Manual, Version 13.3, Chapter 5, D-18 and Chapter 11, I-9 68

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Cardioversion via implanted defibrillator A previously implanted defibrillator can be instructed via telemetry to terminate a spontaneous arrhythmia and convert to sinus rhythm. How is this coded? Coding Comment Use of 93642 is suggested. Discussion Cardioversion code 92960 is inappropriate because it s external; 92961 is inappropriate because it requires catheter insertion. At implantation, 93642 cannot be used with 93641 per NCCI. Because induction is not performed and other components of NIPS may also be omitted, consider appending 52. CPT Assistant, November 2000, p.9 69

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Burst/overdrive pacing via implanted pacemaker A previously implanted pacemaker can be instructed via telemetry to increase the heart rate to convert spontaneous tachycardia, eg. atrial fibrillation, to sinus rhythm. How is this coded? Coding Comment Use 93724. Discussion Because induction is not performed and other components of NIPS may also be omitted, consider appending 52. HRS Coding Guide 2007, p.47 70

Rhythm Devices PPM ICD Physician Hospital outpatient Issue : Turning device off and on with other surgery For protection, devices must usually be turned off prior to other surgery and then turned back on afterwards. Coding Comment In general, switching the device off and on again is not a separately codable service. If a full scale analysis without reprogramming is performed: 93731 or 93734 can be used for pacemakers 93741 or 93743 can be used for defibrillators Discussion By definition, full scale analysis includes: interrogation, evaluation of parameters, interpretation of recordings, analysis of events. Codes are valued to include 15 to 25 minutes intra-service time. 71

Appendix: Composite APCs 72

Quick APC Overview Medicare uses the APC system to reimburse hospitals for outpatient services. CPT codes are the building blocks for APCs. CPT codes are reported on the UB-04 for each significant service during an outpatient encounter. Each CPT code is mapped to one of about 800 APCs with a unique weight and payment rate. Multiple APCs can be assigned to a single encounter depending on the services provided. Many services are designated as packaged into other significant services, with no separate payment made. 73

2007 APCs for EP Services In 2007, the basic and add-on EP codes were assigned to separately payable APCs. CPT Code 93600-93603, 93610-93612, 93618 Description Individual component pacing, recording, induction 93609, 93613 Mapping 0087 EP Record/ Map 93619, 93620 Comprehensive EP study 93621, 93622 CS and LV pacing and recording 0085 Level II EP Evaluation 0085 Level II EP Evaluation 93623 Isuprel infusion 0087 EP Record/ Map APC APC Title SI Relative Weight 0087 EP Record/ Map National Payment T 32.8988 $2,022 T 32.8988 $2,022 T 34.2808 $2,107 T 34.2808 $2,107 T 32.8988 $2,022 93650 AV node ablation 0086 Ablate Heart T 47.4931 $2,919 93651-93652 Other ablation 0086 Ablate Heart T 47.4931 $2,919 93662 ICE 0670 Level II US S 32.2854 $1,985 https://www.cms.hhs.gov/hospitaloutpatientpps/au/list.asp#topofpage 74

2008 APCs for EP Services In 2008, APC assignment and payment was completely overhauled for EP services. CPT Code 93600-93603, 93610-93612, 93618 Description Individual component pacing, recording, induction 93609, 93613 Mapping - - N - - 93619, 93620 Comprehensive EP study 93621, 93622 CS and LV pacing and recording 0085 Level II EP Procedures Q 47.2949 $3,012 - - N - - 93623 Isuprel infusion - - N - - 93650 AV node ablation 0085 Level II EP Procedures 93651-93652 Other ablation 0086 Level III EP Procedures APC APC Title SI Relative Weight 0084 Level I EP Procedures National Payment S 9.5834 $610 Q 47.2949 $3,012 Q 92.8564 $5,914 93662 ICE - - N - - https://www.cms.hhs.gov/hospitaloutpatientpps/au/list.asp#topofpage 75

Composite APCs Composite APCs were introduced in 2008. Rather than following the usual practice of assigning each CPT code to an individual APC, composite APCs are assigned based on the presence of two codes. EP services were considered wellsuited for composite APCs because two significant services a diagnostic EP study and a therapeutic EP intervention are frequently performed during the same episode of care and submitted together on the same hospital outpatient bill. 76

Composite APC for EP Services A single composite APC is assigned whenever a claim contains at least one code from Group A with at least one code from Group B. The composite APC is 8000. CPT Code Group A Code Description 93619 Comprehensive EP study wo induction 93620 Comprehensive EP study w induction CPT Code Group B Code Description 93650 AV node ablation 93651 Other atrial ablation 93652 Ventricular ablation Electrophysiology Composite APC APC Composite APC Title SI Relative Weight National Payment 8000 Cardiac Electrophysiologic Evaluation and Ablation Composite T 134.1189 $8,543 77

Healthcare Economics Information Multiple resources are always available to you: Our website: www.medtronic.com/crdmreimbursement CRDM Coding Hotline: 1.866.877.4102 (option 1) Hours: 8am CT to 5pm CT E-mail: rs.healthcareeconomics@medtronic.com Your Regional Economic Manager (REM) You can find out who your REM is by contacting your Medtronic sales representative or by calling the CRDM Coding Hotline at the number above 79

Advanced Electrophysiology Coding May 2008