Hi everyone and thank you for joining our presentation. My name is Jamie Quimby and I'm a manager of Revenue Cycle Solutions Coding. Today's topic is on advanced EP case studies. We will start by doing a quick review of some of the recent changes this specialty has had. We'll also cover some of the common conditions treated, then review some of the areas of the EP ablations and device service that are commonly asked. Then at the end, I'm going to cover in great detail with you eight real case examples. Just to go over some housekeeping, this is a simulated live webinar, so please note event and CEU credits will be available for those attending the live session. During the next session, if you cannot attend live, CEUs for this webinar may be obtained by watching the on-demand version as well as successfully completing a quiz at the end. So during the simulated live session, the chat box will be open to all. Please limit your comments to specific questions regarding the topic of the webinar. If you have a copy of the slides and are unable to download those, you can request those at the academy at medaxium.com. If you have a copy of the slides and are unable to download those, you can request those at the academy at medaxium.com. When you log into your medaxium account, you will click on the claim CEU in order to access that CEU certificate. The CEUs are for AAPC. These will be available to view and download in that transcript section of your account. We do ask for at least one to two business days to allow our team time to get that certificate uploaded to your account. Again, if you are launching the on-demand version, you will have to complete a quiz at the end in order to obtain that certificate. If you have a copy of the slides and are unable to download those, you can request those at the academy at medaxium.com. Again, this is just the AMA CPT disclaimer. All the codes from this content that we will be covering today are from the American Medical Association. We have a lot of work to do with our ablation services. We have seen significant bundles with our ablation services. With those bundles that they implemented, it really reduced that work RVU value significantly for our E.P. physicians. With our SVT ablation services, what we ended up doing was slightly increasing some of the services. You can see on the additional ablations, the 93655 and 57, those did not have any changes. With our SVT ablation, that was increased from the 1475 to 15. With our AFib ablation, it had a slight reduction as well, but not as much as what they were wanting to reduce it to. You can see they were wanting to reduce the VT to 16, but they compromised and did the 18. As well as the pulmonary vein ablation, they wanted to reduce it down to 15, which would have been significant because they had already reduced it significantly down to 19 back in 2022. Instead, they reduced it down to 17. This was a slide I put together back when those 2022 bundles happened. The AMA did add to the CPT book itself a helpful table, but it didn't have everything listed in full detail. I code E.P. on a daily basis, so I wanted to have something personally that I could look at. I wanted to share this with everybody in case you find it helpful also for when you're looking at these services. It lists everything that's inherent and part of that primary service. And then, of course, all the services that are not bundled that you can separately report. I haven't covered in great detail with E.P. before some of the common conditions that are treated by E.P. Usually when I do the ICD-10 updates every year, I'll cover conditions there. But I thought it would be helpful just to do a quick review of some of the common conditions that we see our E.P. specialty treat. I'm not going to cover an all-inclusive list because, as we know, there are many different conditions that they do treat. We're just going to cover some of the top ones that they treat for our patient population. So we're going to start with the different types of bradycardia. Typically when we see this condition being treated, a lot of times that provider is going to most likely do an implant of a pacemaker device. So looking at that R00.1, that's just sinus bradycardia. It's not further specified. That definitely alone will not cover a pacemaker implant. But looking at the overall condition itself, when a person has sinus bradycardia, the heart rate is usually less than 60 beats per minute. The slow heart rate might be normal for that patient. The type of slow heart rate is often seen in healthy athletic people. Also, this type is not likely to cause complications unless that heart rate does go even slower, down to less than 40 beats a minute. It rarely requires treatment unless, of course, it's causing symptoms for that patient. Usually if it gets to that point, then that's when that provider is going to be looking at a pacemaker implant to treat that bradycardia. With sinus arrest or sinus pause, they could be called either. During a sinus pause, the heart may miss one or more beats because its natural pacemaker is failing to activate the electrical system throughout the rest of the heart. Depending on the cause, there is a risk of complications with this type of bradycardia. If sinus pause occurs often or over an extended period of time, that's when the provider may look at doing an implant of a pacemaker. If there is a cause that is identified, then that provider most likely is going to try to treat that cause first. With sick sinus syndrome, this is definitely a common one we see. That happens when the normal pacemaker of the heart, which is the sinus node, does not work properly. There sometimes are various irregular heart rhythms or combinations of arrhythmias that can happen. People with this syndrome can have a slow arrhythmia or a combination of both fast and slow. Looking at tacky brady syndrome, you'll see sick sinus syndrome and the tacky brady syndrome go to the same ICD-10-CM code. They both have a little bit different of a definition, though. With tacky brady syndrome, this is when the heart beats sometimes too quickly and then it sometimes beats too slowly. This abnormal heart rate problem is often seen in people who have also been diagnosed with atrial fibrillation. It can occur when the heart's natural pacemaker is damaged. There are risks of complications with this syndrome. The patient may have symptoms such as palpitations and lightheadedness. They might pass out and they might be at a higher risk of having a stroke. Treatment, of course, would include that pacemaker being implanted, also medications being prescribed to deal with the heart beating too fast, and then blood thinning medications might be used also to help prevent that stroke. With heart block, this is referring to an abnormality in the way the electricity passes through the normal electrical pathways of the heart. The abnormality or the block with the electrical impulse, it keeps it from continuing through the normal pathways and usually results in a lower heart rate. There are definitely many levels of heart block, as you know. So we have, you know, our complete heart block. We have first degree. There's different options. So it is really up to the physician to be as specific as possible for us to accurately code that heart block. All right, different types of atrial fib. So as you can see, we have different reporting options for the diagnosis portion, depending on the specificity that we have. So with paroxysmal, typically this is a patient that may have symptoms that come and go. Sometimes they last a few minutes or up to a few hours. Sometimes the symptoms occur as long as a week and episodes can happen repeatedly. Symptoms may go away on their own or they may need treatment. Sometimes patients with this have no symptoms at all, though. And I see that a lot in some notes where a patient is found to be an AFib and they have literally no knowledge of that even being present with them. With persistent, this often requires a pharmacological or electrical cardioversion and does not stop within a week. With longstanding persistent, it's persistent and continuous and lasts longer than one year. With chronic AFib or permanent AFib, this is a term that has been long used to describe the condition in people where the abnormal heart rhythm can't be restored. They'll most likely have AFib permanently and often require medications to control their heart rate to prevent those blood clots. Usually with chronic or permanent AFib, cardioversion is not even attempted. Or if they do attempt it more commonly than not, it's usually unsuccessful. Again, I want to stress to you that it's up to your provider to document those conditions to the highest degree of specificity as they know at the time they're seeing them. And if you start seeing a trend where you're having to select that unspecified more often than not, definitely send that feedback to your provider. You know that it is best to always code to the highest level of degree known. So we have two different types of AFlutter and of course we have an option for unspecified AFlutter. So looking at the definitions, AFlutter can be described as typical or a type 1 or atypical or type 2 based on the anatomic location from which it originates. Also atrial flutter can be described as clockwise or counterclockwise depending on the direction of the circuit. Now if you look at EP studies and ablations a lot and you're looking at these arrhythmias, those are definitely common terms that you see documented. I see the clockwise and the counterclockwise documented all the time. Again, it's up to your provider to document that level of specificity though. I wouldn't just assume that it's one type of AFib without the provider clarifying that. So with typical AFlutter, this is usually localized to the right atrium and typically it can be treated successfully with an ablation procedure. With atypical flutter, it is typically localized to the left atrium. Most times this flutter can also be treated by ablation, but it is a more complex procedure with more involved that has to go into it. So sometimes it's not as successful as with the typical. Different types of ventricular tachycardia. We know with the ICD-10-2023 updates, we definitely got more options added with reporting this condition. So healthcare providers categorize the VT as a heart rate that is greater than 100 beats per minute and it has characteristics appearing on an EKG. While the VT varies in severity, it is usually a medical emergency whether a person is tolerating it or not. This is because the condition can quickly turn into ventricular fibrillation, which is the most serious cardiac arrhythmia and it can be life threatening. So you can see now we have four different options just depending on that specificity that is documented from the provider. All right, so here's our two very serious conditions. So with the V flutter or ventricular flutter, this is an extreme form of ventricular tachycardia with the loss of organized electrical activity. It's associated with rapid and profound hemodynamic compromise. Usually it's short lived due to it progressing into ventricular fibrillation. And then looking at that ventricular fibrillation, it is the most important shockable cardiac arrest rhythm. The ventricles suddenly attempt to contract at rates of up to 500 beats per minute. The rapid and irregular electrical activity renders the ventricles unable to contract in a synchronized manner, resulting in that immediate loss of cardiac output. The heart is no longer an effective pump at this point and is reduced to a quivering mess. Unless advanced life support is rapidly initiated, this rhythm can be fatal. All right, so now we're going to cover some of our EP services highlights. This is one of my favorite anatomy pictures, and I'm happy to share it with you. So this is an overall ablation anatomy photo. And as you can see, this is the posterior view of the heart, which is hard to find. So here you can see we have our pulmonary veins. This would be our left side and this is our right. So looking at what a pulmonary vein isolation would look like, you can see how they do this circle around here for the both sides. Again, any additional ablations that are usually treated for sometimes if a atrial tachycardia is present or an SVT, they may do an additional ablation line after they're doing like a pulmonary vein isolation. A common one that I see is our roof and floor lines here, which is right here. So here's our roof. Here's our floor. So we'll cover many case examples when we get to that portion of the presentation. But a lot of questions I get is what if they do a posterior wall box ablation? OK, so this is our posterior part of the heart. Here's our pulmonary veins. This box right here is our posterior wall box. Now, if they do a roof line and they do a floor line and they're doing it as that posterior wall box, that would be only reportable with one additional 9-3-6-5-7 after your pulmonary vein isolation is completed. Now there and I do have a couple of cases that we are going to cover. There are some times where a provider does the pulmonary vein isolation. They do that roof line because the patient's still having signals. After they've completed that roof line, the patient continues to have signals and they decide to go down and do a floor line. In that case, there can be arguments made that you can report that twice because the provider was not intending to do that box ablation. They're addressing the distinct arrhythmias that are still present. Again, it's all going to come down to what is documented by that physician and the level of specificity they're giving you. Another one that we commonly see post-pulmonary vein isolation is the patient has either a history of atrial flutter that has been clinically documented, or they are going into atrial flutter during the procedure and the provider is going to do this CTI line. You can see this is how we abbreviate it. That is where that line is located right here. Again, this is a helpful photo. I use it often when I'm coding ablation services. Looking at the overall definitions and how these are defined by the AMA, these are the two additional ablations that we can report. They are the most commonly asked and often very confusing area when trying to apply to the documentation. We have one specific to any additional SVT or discrete mechanism, I should say. So the 93655, this can be reported with that SVT ablation, the VT ablation, or the AFib ablation. The 93657, this is only allowed to be billed with that pulmonary vein isolation ablation. So that 93656, it's only separately reportable with that. There is medically unlikely edits assigned to both of these services. Both have two units reportable. If this could mean if you have a very complex case where they did a pulmonary vein isolation and it's supported, you could bill this 93657 two times, and you can also bill this 93655 up to two times, just depending on, again, how much you have documented and what would be supported. Six of the eight case examples that I'm going to cover with you in a little bit all cover additional ablation services. I hope that when you listen to this presentation today, you walk away with a little bit more confidence and knowledge in coding for these services. I know from personal experience that these can be very complex at times. So again, I hope all this helps you today. When it comes to that 93655, these are guidelines that are actually printed in the CPT book. If it states the primary tachycardia that is ablated during post-ablation testing of a different arrhythmia is identified, it would be considered a separate mechanism from that primary tachycardia. Therefore, it could be supported to report that 93655. They have also added additional verbiage on reporting that 93655 with the VT ablation, that 93654. Here it states the 93655 is listed in conjunction with that 93653 and that 93654 when the repeat ablation for treatment of an additional VT mechanism or SVT mechanism is identified. And CPT guidelines do allow for reporting the 93655 also with that pulmonary vein isolation ablation when an additional non-atrial fibrillation tachycardia is being treated. This was a CPT assistant article that was released back in September of 2019. There are actually two articles that were released back to back per year. This was the first one and it gave great further clarity on billing this 93657. What they're asking in this question is would it be appropriate to report that 93657 for complex fractionated atrial electrograms, which you may often see called CAFE lesions, ablated post-pulmonary vein isolation when there's no evidence of continued atrial fibrillation. So they came back and responded and said yes, this is allowed to be billed now. So once that pulmonary vein isolation is complete and the provider is doing the testing and they see these CAFE lesions and they decide to further ablate that area, you can report that 93657 then. So secondly, this one was released in November of 2020. So this was the second CPT assistant article that was released. In this question, they asked would it be appropriate to report that 93657 for a patient with persistent atrial fib if additional ablation lines are performed post-PVI and there's no further AFib or CAFE lesions noted. Their response here was surprisingly yes, we can report this additional ablation. This was a huge clarification for reporting purposes. So what they're stating here is that if the patient either has documented paroxysmal or persistent AFib, whether they are in AFib or sinus rhythm at the time of the treatment and the provider performs those additional ablation lines, such as that roof line, you can report the service. The only thing is that they still have to meet that medical necessity. So they further clarified that said even though if AFib is not present and those CAFE lesions are not present, there should still be some type of abnormality, whether it be fractionated potentials or any linear lesions that are present to support billing. They may not have to be in the arrhythmia, but it still should show there's a medical reason for that additional ablation to be performed. So with this next CPT assistant article, I get asked all the time, what if there are two primary arrhythmias that are scheduled to be treated? So provider knows patient has a clinical history of maybe atrial fib and atrial flutter. So if we have that present, how do you report that? So this was the closest article I could find that was similar to that type of question. So here in the question is asked, please confirm what determines the primary ablation performed. Should the coding be based on the primary rhythm as determined by the physician, or is it based on the order in which the abnormal rhythms were treated? The answer is the primary arrhythmia is the clinical arrhythmia that the patient is being treated for. So remember, that's the key phrase. It's the clinical arrhythmia. So sometimes the patient may be coming in for a pulmonary vein isolation, but AFib is never induced during that procedure. Well, that doesn't mean you're not going to report anything. The clinical arrhythmia has been documented, present, the provider is treating it. So that's further clarity there. Again, you would code these based on the hierarchy. So in that example, if we have a pulmonary vein isolation, that is the highest ablation service. So if you have that performed and then maybe the provider also wants to perform that CTI line because that patient also has that history of clinical atrial flutter. Neither arrhythmia is induced during this study, but again, the patient's chart supports these conditions. You would report that 93656 as your primary and then you would report the 93655 as your additional ablation for the flutter. Also, it does not matter the order. So say the arrhythmias are present during the procedure. But what if they decide to do the flutter line first and then they go and perform the pulmonary vein isolation? Doesn't matter the order and how you're treating them with reporting. You're still going to report based on that highest hierarchy. So even if you treat the flutter first and then you treat the AFib, you're still going to report your AFib as your primary and then your flutter with the additional ablation. All right, let's cover some common questions with device services that I get. So how do you report if a patient's coming in for a generator change and they need a right sided lead procedure performed? This can get confusing sometimes. So what guidelines state with CPT is that you bill for what was removed and then you bill for what was implanted. So if you have maybe a dual chamber pacemaker in place and the patient's right ventricle lead is no longer functioning, the provider goes in and just caps that lead. But they're going to do a generator change at the same time because the battery is at the end of service. In that case, you would report your 33233 for your removal of your generator. And then you're going to bill for the 33207, which would be a new pacemaker generator and a new right ventricular lead placement. So that's the guidelines with that. Also, what if you're doing an LV lead? So LV leads are coded a little different. So if the patient already has an existing system and they're coming in for that generator change but maybe their condition has gotten more severe and now they need that left ventricular lead placed also. So how we code these is we code for the generator change out and then you code additionally that left ventricular lead placement. So with this example, we have a multi-lead system. It was a dual-lead system and then they are converting that to the multi-lead with the addition of that LV lead placement. So here we would code the 3, 3, 2, 6, 4 because the patient's leaving with three leads and then you're gonna code that 3, 3, 2, 2, 5 which would be the new addition of that LV lead. And it would be the same for pacemaker systems. So no difference in that coding generator change and then you're coding for the new addition of that LV lead. Only difference is if there is any time there's a right-sided lead procedure, that's when we have to code what was removed and then you code what was implanted. The HIS bundle lead is definitely becoming more and more popular and I'm seeing a lot more of these being implanted on a daily basis, I should say. So how do you report that procedure though? Current guidelines now tell us because of where the lead is placed is we just code it to where that location of the HIS lead placement happens. So if it is placed below the valve in the right ventricular, you would code it as an RV lead. If it's coded above that right atrium, you would code it as an right atrial lead. So you can see here, this is where they would place the lead and just depending on whether it's in that atrium or lower down in the ventricular area would depend on your placement. They're placing these now for that resynchronization therapy like that LV lead treats, but unfortunately it's not placed in the left ventricular area. That 33225 is specific to that left ventricular. So that's why you cannot report that. Furthermore, on the 93600, sometimes that is performed when they're looking at lead placement for the HIS bundle. CPT manual specifically states on the 93600, which is HIS recording that this is reportable when trying to identify any tachyarrhythmias being present. So again, when you're placing the lead and they're doing this imaging, it truly is for roadmapping in a sense. So you know how sometimes with our devices, they do a venogram at the initial start of the case, that this is the same concept. They're doing this essential imaging, but you're trying to find the precise location to place that lead. So it wouldn't be separately reportable because they're not doing it for a diagnostic purpose for that tachyarrhythmia. Now to cover venograms, which I mentioned. So the venogram to place a lead is included as part of the lead placement and is not separately billable. If the provider has to do a venogram due to suspected blockage or other medically necessary reasons, not just simply to place that lead, you might be able to report it, but it's gonna depend on the level of detail that is provided in the documentation. Again, it all comes down to that documentation and the medical necessity being documented. The report should clearly state what the intent of the venogram is. On this CPT assistant article, it was asked during the insertion of a dual chamber ICD, the physician indicates performing a left subclavian venogram to facilitate entry. Would it be appropriate to bill that 95820? They came back and said, no, the service described is not a true diagnostic venogram, but it was used to guide in the placing of the lead. So again, if it's not being done for diagnostic purposes and that's not clearly documented by your provider, then you cannot bill for that service. All right, let's cover some NCCI edit reminders. First one, again, I have mostly physicians asking me this question, not the coding community. So can you bill ultrasound guidance with an EP procedure? And unfortunately the answer is no, and will always be no as long as this rule is in place. So this is from the Medicare NCCI manual itself. This was actual language from the chapter 11. And you can see the portions that I've highlighted in red where they talk about the ultrasound guidance is not separately reportable. Then they further go on to say the CPT code ranges. So the 33202 through the 49, that is all of our cardiac device implants for our EP specialty. Then we have the 93600 through the 93662. That's all our cardiac EP studies and ablations. So there's no way around that. There's no modifier allowed to override this edit. It is one of the more strict edits that we see. So if you have a provider asking you that and they wanna see it in writing, you can definitely find that in that Medicare NCCI manual. Another one I see, and more commonly with the VT ablations, I see providers trying to bill for the arterial cannilation or the arterial line, as we call it. So this, when looking at the NCCI manual and the edits, these bundle into a global surgery package. So even a zero day service, as they're considered as being part of the main procedure being performed. It is very common to see during that EP ablation, especially that ventricular tachycardia ablation, where the provider is placing an arterial line at the start of the case. They're doing this to help monitor the patient during the study. So because it's related to the study, it cannot be separately reportable. If you have supportive documentation that does show it is unrelated to the procedure, then you could report it. And then you would just override that edit with the appropriate modifier. Again, it's very rare that I see that it's documented for other reasons other than monitoring that patient for that procedure. Cardioversion, this one's definitely a popular question that we get a lot. So can you bill a cardioversion when you're doing an EP procedure? So let's look at the overall definition of the cardioversion. This is how the AMA has defined it. It is an elective procedure. So what does that mean? It means the patient knew they were gonna have the cardioversion. There's an order place. There's consent from the patient. They knew it was gonna happen. The edit that does allow for a modifier to override it, but again, you have to have supportive medical necessity. And again, it's an elective procedure. So it can't be just done to get the patient stable after your provider has started their EP ablation and study. And we see that happen a lot. Patient comes in, they do the ablation, patient still will not come out of that arrhythmia. So then they shock them. That's not billable in that case. I do have a case example that I'll cover with you where it was pre-planned. It was discussed with the patient and it was done at the start of the case. So I'll be able to point that out with how that looks. Of course, with our specialty, the most common one that we would bill an EP would be the 92960. 92961 is done through an open access procedure. This would not be your standard EP provider, more or less be a surgeon of some sort. All right. Program stimulation and pacing after intravenous drug infusion. So we typically call this medication testing in our world. That's the 93623. Medicare is specific with this service and stating that it cannot be reported if it was performed post-ablation and only done to confirm the adequacy of the ablation procedure itself. So again, documentation is very important here from the physician in detailing why they are administering the medication post-ablation. Sometimes they administer the medication pre-ablation and then they do it post-ablation. So you can only report it the service once. It only has a MUE of one. But it doesn't matter the timing of when they do it. If they do it only after the ablation, but they're doing it for diagnostic purposes for testing, then you can report it still. It's only when it's done to confirm the adequacy of that ablation that was just performed. And sometimes that is all that is documented. So then you wouldn't be able to report it in that case. So again, it just comes down to that level of detail from your physician. On the periprocedural device evaluations, this is when the patient has a system already pin in, they're coming in for their procedure, the provider's evaluating the device, they're turning off or changing some of the parameters, they perform their procedure. And then after the procedure is complete, they will reevaluate the device and they will readjust it. So here with our ablation procedures, there's an NCCI edit in place with the 93654 and the 93656. And there is no modifier that is allowed to override that edit. So that's another strict edit in place. So even if they do make changes and evaluate the device, if it's billed with the 93654 or that 56, there's no way to report it still because it's not allowed. Now on the SVT ablation with our 93653, there is no edit with either the pacemaker or the defibrillator system. So depending on whichever type of system they have, if this is performed and supported, you can bill for it with the 93653. All right, so we have eight case examples to cover. I'm gonna start with a couple device procedures and then we're gonna finish off the rest with all of the FUN EP ablations with all the additional ablation case examples we have. So here we have a pacemaker generator change that had a right-sided lead procedure. Here you can see in the indications, the patient has non-ischemic cardiomyopathy. They have a left bundle branch block with improvement in the ejection fraction. Patient also has a history of atrial flutter. Patient is noted to be in sinus rhythm the day of the procedure. Then you can see in our procedure details that I have highlighted here. We have the incision was extended over the pacemaker. The area was open and then the generator here was removed. The device was removed from the pocket. The leads were then disconnected from the device. Furthermore, this is all standard verbiage that they put in there where they're adding the lidocaine, talking about the puncture needle to get into the axillary vein. Sometimes it's the axillary, sometimes it's the subclavian. Multiple passes were initially unsuccessful and then furthermore, you go down and you can see that they were able to get this pass through the subclavian region. Then that atrial lead was placed. It was then sutured to the pectoral muscle. So that was just them securing that lead in place. Again, dissection was performed to extend the pocket inferiorly to better accommodate the new device. So will we be able to bill for this? Sometimes people think it's a pocket relocation. There's no pocket revision code available anymore. There used to be years ago, but they eliminated that code many years ago. So this is not a true relocation of the system itself or the pocket, I should say. They're making it better to accommodate the new device. So it's the same pocket, they just extended it down a little bit to accommodate for that new device. So nothing separately billable there. So here, what we had is a 3,3,2,3,3, which was a removal of that generator. We have a 3,3,2,0,6 with an insertion of a new pacemaker generator with that new atrial lead. Modifier KX was not supported by the diagnoses we had. So when looking at the LCD or the National Coverage Determination from National CMS, we are allowed to append the SS modifier. And so that's why that one's appended for that case. Case number two is a dual chamber pacemaker implant with a left bundle branch pacing lead. This is a common type of service that I'm seeing done a lot now. So here we have a patient that presented to the hospital with syncope. They were noted to have conduction disease with bradycardia. They also converted from proximal AFib. Patient meets the criteria for a pacemaker implant as there is that sinus node dysfunction, but they also have confirmed tachybrady syndrome with that proximal AFib also being present. So here they talk about they're doing that dual lead system. A left bundle branch pacing lead will be implanted also. So here we have our consent, which is standard verbiage. Description of our procedure in the highlighted areas. Here you can see we have the venogram was obtained, showed excellent readings for going in and placing that lead. Furthermore, they go down and they're gonna do that left bundle branch lead placement first. They successfully deploy the lead. They then suture it and then they do some testing on it. That again is all standard verbiage. Then they go on to place that right atrial lead. You can see here further. They then create that pocket to place the pacemaker generator itself. The leads were then cleaned and dried and attached to that pacemaker device. And then they close up the patient. So here, furthermore, they talk about the hardware and you're typically always gonna see this in a device procedure. They're always gonna talk specifics with the type of hardware that's being implanted, the manufacturer, the model number, the serial number, all those details will be there. And sometimes you can find a lot more information in that level of detail. So here we can see we had a Medtronic dual chamber pacemaker system place. We then have the right atrial lead, which we know was here. Well, then it says the right ventricle lead was placed in that left bundle branch location. So there, we didn't have that level of detail initially in the report, but that further clarified that now we know where that left bundle lead was placed. It was in the RV area of the heart. So here we have 33208 with our KX modifier for that tachybrady syndrome and that proximal a-fib. All right, now let's do some fun additional ablation cases. As I said, we have six to cover. They're all different. So these are real case examples. So with the first one here, we have a patient that has a history of proximal a-fib. You can see her episodes have become more frequent, lasting several times a week and lasting for about three hours. Patient's unable to tolerate any rate controlling medications. So therefore she was referred for that catheter ablation. Typically with pulmonary vein isolations, I cannot think of any time where a provider's doing moderate sedation. Typically a general anesthesiologist is involved and they are administering and monitoring that patient. I always just like to know that when I'm looking at a case. So that's why I have it highlighted. Here, you can see that arterial line was placed again. It's placed for the left radial artery for continuous blood pressure monitoring during the case. So again, it's not done for any separate reason. It's done so it's considered part of the study. Here we have those catheter placements. Furthermore, just talking about the different catheters that are being placed, the areas of the heart it's going to in the right atrium. Again, they then move it down into the coronary sinus. The intracardiac echo, this was all bundled last year. We can't separately bill for that anymore. Would not with the pulmonary vein isolation at least. So again, here's just them going into the different areas of the heart, doing the testing. Here, the patient they say, they started at the case in sinus rhythm. They then start doing a voltage mapping of the left atrium. So now this is them doing that testing for the ablation. They were then able to induce AFib. This will sometimes stop. Burst pacing would be repeated and then the patient would go into a typical atrial flutter which would self-terminate. They then started the ablation procedure itself on the left side. They did the left superior and the left, sorry, I clicked too fast, the left inferior pulmonary veins until that block was demonstrated. Then they do a partial isolation of the left atrial appendage. Now they're not saying, they haven't completed the pulmonary vein isolation. So when you're looking at this, you can't start considering any additional ablations at this point because the 93657 is specific in stating post-pulmonary vein isolation testing shows either the cafe lesions, AFib persisted or any abnormalities. So we have partial isolation going of the left atrial appendage by ablating through the ridge, roof and anterior side. Then they go onto the right side of the pulmonary veins. So this is also considered as part of that 93656. Okay, then they finished the pulmonary vein isolation and now they're inducing an atypical atrial flutter which then degenerated into another atrial fib. So then they go back in and do a roof line by joining that left superior vein and that right superior pulmonary vein. This terminated the atrial fib back into sinus because there wasn't an inducible, typical right-sided flutter at the start of the case on our last page. The provider then goes in to do a CTI line ablation for that. So then they complete that. Ablation was made across that atrial isthmus and then further testing was done. They induce atrial fib again. It would self-terminate within 30 seconds. It was felt that there was still further triggers of AFib remaining. So ablation catheter was placed into the distal coronary sinus and AFib or ablation was made from that distal coronary sinus. So they then completed that. The ablation catheter was placed back into the left atrium and a floor line was then completed. Burst pacing in that high right atrium still was able to induce AFib. That would self-terminate again within 30 seconds. While in AFib and mapping, it showed that now the patient has fractionated atrial electrograms. So that's just another way of saying those CAFE lesions. So that was showing in the septum. So now they've done an additional ablation there for the CAFE lesions. Post that, and they were still able to induce AFib. This would then organize into a focal atrial tachycardia before terminating into that left atrial appendage. So because that atrial tachycardia is now present, they're going to do a left atrial appendage ablation. It did not further induce AFib, but did induce another slow atypical afloater at that point. So you can see here, we're already meeting the complexity of the MUEs allowed to be reported because we've hit more than the two minimum here. Again, they did additional ablations made again through that ridge roof and anterior side of the appendage. An anterior wall line was made there. And then that arrhythmia terminated back into sinus. It then started the patient on isoprel post ablation. All they say right here is the pulmonary veins were confirmed electrically isolated. So this is telling me this was not done for any diagnostic purpose. It's just showing me that it was done to confirm the ablation success. So want to point that out. There's no level of detail here that we see that would tell us we can report that isoprel being infused. So here we have our conclusions with all the different ablations that were performed. And then our final coding for here is gonna be our pulmonary vein isolation for that proximal AFib. We then had that 93657 for that roof line. This was the additional roof line that was done after that pulmonary vein isolation was complete. Then again, we had that additional ablation in that coronary sinus for the AFib. Of course, we had AFib persist many other times, but we hit the MUE of two. We have 93655 for that typical AFlutter ablation to the CTI. And then the 93655 for that left atrial appendage ablation that they performed. And then nothing on that 93623 for the medication testing as it did not show anything other than it was confirming the ablation efficiency. All right, so case number four. This is a pulmonary vein isolation plus additional ablations plus a cardioversion. So here in our indications, we see we have a history of non-ischemic dilated cardiomyopathy. We have an ejection fraction of 35 to 40% history of VT, as well as symptomatic persistent AFib and AFlutter. Patient does have a dual chamber ICD in place. His atrial fib and flutter are both symptomatic. He presents for AFib ablation and AFlutter ablation, as well as a planned cardioversion. Normally, if I'm coding a procedure like this where they're saying that, I will physically go to the order or I will go to the H&P where the order was placed from the physician and verify that that is in place because with an electrical cardioversion, it is an elective procedure. So you have to have that order and consent on file. With this particular case, it was on file, it was confirmed. So I just wanted to let you know that on that end, it was supported. Procedure performed, you can see all the CPT codes. This was actually what the provider put in. This is what we call the wishlist. We don't code from this, but we can use it as a guide to try to see what the provider said he did. Here, of course, you can see that they are adding the cardioversion, but they're also adding peri-procedural defibrillator interrogation and programming. Now, we covered a few slides back where this 93287 can never ever be reported with the 93656. There's no way to override that edit, even with a modifier. So even though the provider says he did it, and even if he did do it, we still wouldn't be able to report it, unfortunately. Then they talk about the sheets access, the changes, and then the catheters that they used. Again, anything with ICE imaging, CARTO with 3D mapping, and then your transeptal catheter, those are all bundled in with your 93656, so we can't separately report those anymore. So here, they talk about the transeptal puncture. Then they give the readings from the intracardiac echocardiography that was done. Again, nothing separately reportable there. It's bundled in with the primary procedure. Going on into our ablation itself, then they always talk about the informed consent was obtained, general anesthesiology was used. Pre-ablation baseline rhythm patient arrived in AFib. Then they talk about reviewing the ICD. They then turn off therapies and all that. Unfortunately, again, we can't bill for that for this case. So right down here, well, here we talk about the catheters are positioned in the coronary sinus. They use the intracardiac ultrasound again. And then right here, prior to the ablation, we cardioverted the patient back into sinus rhythm as planned. So here we have a case. It was the order and consent was on file from the patient. Provider had that discussion. So the patient knew this was part of the plan. It was performed before any part of the case started. So in this case, the cardioversion would be billable. So post shocking the patient, it did terminate the atrial fib. They then proceeded with that pulmonary vein isolation. So here they started by isolating the left pulmonary veins, and then they go into testing. You can see what the left side, then they moved to the right side pulmonary veins, which showed it had a considerable scar. They were then effectively isolated at baseline. The patient's AFib then persisted. So they went in and proceeded with creating a left atrial roof line. A series of lesions were created along that roof, connecting the areas of the left superior pulmonary vein and that right superior vein. After that roof line ablation, the catheter manipulation, the patient then went into an atypical AFlutter. So then they move the catheter and they go and apply ablation to that region. For that flutter, it did terminate the atypical AFlutter, but however, a new AFlutter with a different mechanism then developed. They then mapped that second AFlutter to the location, which was the CTI. And then they did that typical right-sided atrial flutter ablation. The patient then went into a new third atrial flutter. Due to the extensive atrial scarring and the multiple flutter seen, they then decided to end the case and did not proceed with any further mapping or ablation. They then cardioverted that patient again, but however, after the cardioversion, the patient went back into yet another atypical AFlutter. So we are able to report that initial cardioversion, but say that one wasn't part of the plan and it wasn't performed at the start of the case, and then this one was, you wouldn't be able to report just this one because it wasn't part of the plan. The provider at that point was just trying to get the patient back into sinus rhythm. So post-procedure, the patient did leave in atrial flutter. Post-ablation, they then re-interrogated and reprogrammed that ICD device. Again, can't bill for that, unfortunately. Not with the pulmonary vein isolation. This is just our summary. So here we have 93656 for that pulmonary vein isolation for the persistent AFib. We then have the 93657 for the roofline ablation, 93655 for that atypical flutter ablation, and then 93655 again for that CTI ablation for that typical flutter, and the cardioversion overriding the edit with that modifier 59, or the X modifiers just depends on what your carrier prefers. And of course that was for the atrial flutter at the, or atrial fib at the start of the case. All right, case example number five is another pulmonary vein isolation. And this also includes an atrial flutter ablation. So again, we have a patient with a history of proximal AFib, also, sorry, atrial tachycardia and atrial flutter. So we have three conditions documented. Here again, we have general anesthesia was administered. Here we talk about ultrasound guidance. They even added that permanent record being available. Unfortunately, that is another NCCI rule that they do not allow for reporting it no matter what. There's again, no modifier allowed to even override that. Here they talk about the catheters that were inserted. They went to the right atrium, the ventricle, the HISS, and that's where they're doing their EP study. They then advanced it to the left atrium, do that transeptal puncture. So all that, of course, is part of your primary procedure being reported. Here they talk about the left atrial recording and pacing. Again, that's not separately reportable. It's part of that primary procedure. Patient did arrive in normal sinus rhythm. They then did drug stimulation with that isoprel. So they're doing that drug testing, trying to induce that arrhythmia. They then talk about prior to the transeptal cath that they're doing. Ice imaging was performed. 3D mapping was performed. Again, nothing separately billable for that. This is the type of ablation technique that they're doing. So that's part of, again, your 93656. They talk about the pulmonary veins were then mapped and demonstrated entrance and exit block. They talk about the esophagus temperature. Typically with that pulmonary vein isolation, because they're so close to the esophagus, they are highly monitoring that area for the temperature to make sure that patient's staying stable. So that is common verbiage that you're typically gonna see in that type of procedure. Adenosine testing revealed no recurrent pulmonary conduction. Post-drug infusion pacing was performed also, which confirmed the pulmonary vein isolation. And then the patient also had that documented atrial flutter. So therefore the provider did that typical atrial flutter ablation and did that CTI line. So here we have the successful ablation and isolation of the pulmonary veins. And then we have that successful ablation of that typical A flutter with that CTI line that they performed. There was no inducible tachycardia post-pulmonary vein isolation. So here we have the 93656 for that pulmonary vein isolation, the 93655 for that clinical typical flutter that was documented, and then the 93623 for that medication testing that was done at the start of the case. If it only would have been done post-case, I would have questioned the provider's intent, but because they did it at the start of the case and they were trying to induce that arrhythmia, that's why we're able to report it. Okay, case number six is another pulmonary vein isolation for atrial flutter. So again, we have our wishlist here from our provider. They say direct cardioversion. This was a case where I could not confirm that that was part of the plan. There was no order and consent on file from the patient. So that's why I always confirm that before just going off of what is in my wishlist. Of course, we have general anesthesiology involved. Patient arrives to the lab in atypical A flutter. You can see the testing here with the cycle links and all that. They then go talk about the CTI was similar. So this is just them testing. The mapping and ablation catheter was in advance to the right atrium. Additional testing, 3D mapping was performed in that area. That's what the CARDO system is, that 3D system. Then they do the transeptal puncture with the assistance with the ice imaging. Again, part of the primary procedure being performed. Then additional imaging's done, mapping of the left atrium. Here's our pulmonary veins. So left pulmonary vein and right pulmonary vein appeared to have reconnection. The inferiors appeared to be isolated. So it looks like the patient had prior ablation done. And sometimes when that happens, it doesn't mean they have to fully ablate all the pulmonary veins again. It's only what is medically needed. So if they are coming back in for another repeat pulmonary vein isolation and only part of the pulmonary veins need to be isolated, you don't have to reduce the service by any means for reporting. They're still completing the service and what is medically needed for that patient at that time. So then they talk about A-flutter appeared to be encircling the right inferior pulmonary vein. Catheter ablation was then positioned into that area and ablation was performed. The pulmonary veins were then re-isolated using the antral approach. The A-flutter then continued. So additional mapping was performed and they mapped that A-flutter to the mitral isthmus line. So then they performed that line there to get rid of that flutter. And then despite ablation, the A-flutter continued, but it then changed into another mechanism into a typical A-flutter. So at that point, they finished that line that they were doing and completed it. Despite that, the A-flutter still continued. So attention was then turned to the posterior left atrial wall. And they performed a left atrial roof line. Again, the A-flutter continued. So then they did a box isolation of the posterior left atrial wall. Now remember that roof line is part of that box. You have your roof and then you have your floor line. So that's all part of that box. So now I know they did a box ablation. Again, the A-flutter is still continuing. So they retested the pulmonary veins. They still appear to be isolated. They do further testing. And now they're finding the fractionated electrograms present, still noted on that posterior to the lesion set at the left inferior pulmonary vein. They were also shown on that 3D mapping. So those fractionated atrial signals, those were targeted and ablated. Despite that, the flutter still continued. Now the catheter is withdrawn to the right atrium. The CTI was interrogated and seemed to show a conduction block with the exception of small low amplitude electrograms. So this is still showing some abnormality. So therefore they decided to target and ablate that area also. All right, and then going further, despite all those ablations, the flutter still continued without any significant change. The complex fractionated electrograms posterior to that left inferior pulmonary vein were also then targeted and ablated. The line connecting the left inferior and right inferior pulmonary veins were also carefully examined and additional ablation was performed. Again, when you're looking at the anatomy of that, going from the left inferior to that right inferior, that's all gonna be still centered within that posterior wall box. In addition, along the coronary sinus roof was performed from the left atrium in effort to eliminate any residual connections from that left atrium. Once ablation was complete, the majority of the posterior left atrial wall had been treated with ablation. All ablation lines appeared to be intact. Despite that, the a-flutter still continued. So that's when they elected to cardiovert that patient into sinus rhythm with that shock. So that's why this is not reportable right here. This was not planned or part of the procedure. They just could not get that patient out of the atrial flutter, the ablations they performed, so that's why they cardiovert it. So there it's not meeting that definition of elected procedure. They call it an unsuccessful atypical a-flutter ablation, successful pulmonary vein isolation, and then all the additional ablations that they performed in our summary. So here, our primary arrhythmia was that atypical flutter. That's why they were bringing the patient back in. So here we have a PVI ablation, but it was for atypical a-flutter. So we have the 93653. We then have the 93655 for that additional ablation for that CTI line that they did for the typical flutter. Then they did the additional ablations for that fractionated signals that were found. They did more, obviously, than these three ablations, but we are meeting our MUE two units, so that's why we're reporting these. They also did transeptal puncture, which is separately reportable with the 93653. Our ICE imaging is also separately reportable with the 93653. And again, we cannot bill for that cardioversion because it was not elective. It was done post-ablation just to get the patient out of that flutter that the ablations could not get the patient out of that arrhythmia. All right, case number seven, we have another pulmonary vein isolation, and we also have a posterior wall box ablation, and then we have a separate mechanism. So here we have a patient with symptomatic persistent AFib and AFlutter, and they're coming in to have ablation for both of those arrhythmias. Here is our wishlist again. Again, here's our anesthesiology providing sedation. This is our typical consent given from the patient. This is our catheter placements here, the sheets that they used, talking about the intracardiac echo, location of the esophagus, all that standard verbiage, transeptal needle was then used. Patient did present into the lab in sinus rhythm, but they did develop into a typical AFlutter. Remember, part of our procedure includes both AFib and AFlutter, so it doesn't matter how the arrhythmias were induced or which order that they are ablated. So here you can talk about, you see the sheets are placed. Radiofrequency ablation was then performed on the posterior aspects of the left atrium. They then talk about doing the pulmonary vein isolation on all the pulmonary veins. Entrance and exit block was demonstrated. Within that pulmonary veins, the patient then remained in AFib, therefore a left atrial roof line was performed by extending the lesion set from the posterior aspect of the left upper pulmonary veins to the right upper. They then next performed an inferior LA line was then performed. So this is still part of that box. So you have the roof line, you have an inferior line, and then you have your floor line. So all of those are within that box. Now here, the provider is not stating patients remained in AFib after they do the roof line. So this was all part of the plan. And then you can see on the posterior wall, the area of the posterior box between the four atriums were targeted individually, and then all the signals were then ablated. They then infused nine milligrams of adenosine. It was given in each pulmonary vein to assess for inducible atrial tachycardia or diagnosed presence or absence of conduction along the lines that were done. So this is being done for diagnostic purposes, not just to confirm that adequacy of the ablation. It was also given to unmask the conduction on the posterior wall. It does show the pulmonary veins remained isolated with no inducible atrial tachycardia present. And because that typical AFlutter was present at the start of the case, and it was already planned due to the clinical AFlutter history, the provider then did that CTI line ablation. They then did testing post ablation and confirmed that block across the CTI. Then they performed a comprehensive EP study. So sometimes they'll do that post ablation trying to induce that arrhythmia again. Here it showed everything was normal and patient state and sinus rhythm. Here we could see our successful pulmonary vein isolation. We then had our posterior wall box, and then we had our CTI line for the typical flutter. So here we have our 93656, our 93657 for that box ablation, the 93655 for the CTI line, and then the 93623 with the medication testing. All right, here is our final case, and this is an SVT ablation with a separate mechanism. Our primary indications here is atypical AFlutter. It says postoperative diagnosis, we had an atrial tachycardia in the typical AFlutter as well as proximal atrial fibrillation. All right, so description of the procedure here, it shows there was a TEE performed, but it does tell us to refer to the dictation, typically with our ablation services, there usually is a TEE service performed. Most times it's done by the EP provider, sometimes it could be done by a colleague in the practice, but it is separately reportable. And what they're usually looking for is any type of thrombus that might be present prior to them ablating. So here we can see that there was no thrombus present. Following the TEE, they talk about patient being prepped and draped, then they get the catheters in through ultrasound guidance. They then talk about the transeptal puncture, and then following that, they're going to do a complete EP study with that pace and recording, as well as that 3D mapping with the CAR-TOE equipment. Then pacing and recording were obtained in that right atrium, left atrium via that coronary sinus, the his and right ventricular area. Later on, the recording were then obtained of the left atrium, left ventricular via that transeptal puncture. The patient did present in a narrow complex tachycardia. While manipulating the catheter to the coronary sinus, the arrhythmia terminated. While pacing in that coronary sinus, they evaluated the previously ablated CTI line. It did show it had recurrent conduction. With several lesions, it looks like it was re-ablated successfully since it did show that it had recurrent conduction present. Following that, the patient was in sinus rhythm. They then evaluated the SVC. It was previously isolated, so it looks like it shows recurrent communication to that right atrium. So therefore, because that abnormality is present, they then re-isolated that SVT. Then they go on and go into the pulmonary vein anatomy. It talks about the previous isolated pulmonary veins were assessed. All four veins appeared to have durable entrance and exit block. During catheter manipulation, the patient spontaneously developed atrial fib. Given occurrence of the atrial fib, which was sustained in spite of ongoing pulmonary vein isolation. So right there, that's confirming the previous pulmonary vein isolation that was performed is still showing they are isolated. So then they mapped to the posterior wall of that left atrium, which revealed the complex atrial fractionated electrograms or again, those CAFE lesions. They then decided to perform a posterior wall isolation due to those lesions being present. So then they connected the inferior lines to isolate that part of the posterior wall. In spite of those lesions, that patient continued to be in AFib. So therefore they then cardioverted the patient. So again, we have no order consent on file for that and they're doing it as they're performing our ablation case. So just because you induce the arrhythmia, you can't cardiovert it to get rid of it and bill for it. You can cardiovert them of course, but you can't bill for it. So following that cardioversion, there was still ongoing conduction in that posterior wall. The patient then developed spontaneous what appeared to be an atypical A flutter. So then therefore they go and ablate those areas. The flutter did not prolong or terminate. Further investigation revealed the patient is actually an atrial tachycardia originating from that location. Detailed mapping revealed an atrial tachycardia originating from the slow AV nodal pathway into the lip of the coronary sinus. Lesions in that location resulted in immediate arrhythmia termination. Full lesion was delivered and arrhythmia was no longer inducible on and off isopropyl. The CTI block continued. Post-lateral right atrial wall ablation function was also tested and found to be within normal limits. They then reinserted the catheter into the left atrium and then did a posterior wall isolation was performed. At that point with rapid stimulation and on and off that isopropyl failed to induce the SVT, the atrial flutter, or the AFib. So here they're doing testing post-ablation, but they're trying to induce these arrhythmias. All right, and then that just wraps up that case. Here's our summary, which talks about our TEE. Please see the dictation, intracardiac echo, transeptal puncture, all the summary of all the ablations that they performed. And of course the cardio version that we do not have consent or order for. So since the pulmonary veins still remain isolated and our primary intent was also for our flutter, we're gonna build a 93653 with our typical AFlutter. The 93655 can be built twice with two units and we had an atrial tachycardia. We also had that posterior wall ablated for the AFib that was induced. Because we're building the 93653 as our primary, you can build a transeptal puncture and the ice imaging. There was medication testing done at the end. And then we also had left ventricular pace and record that was documented at the start of the case when they were doing the EP study portion. All right, and with that, it'll bring us to our questions. Since this is the simulated live presentation, you are able to type in your questions in the chat box. We will review those questions. We will also compile those questions at the end as we typically do with our webcast and we will add that document to our MedAxium Academy. So you will have access to that later. Some helpful resources. Again, the NCCI manual is definitely a wealth of knowledge for our EP studies and ablations and device procedures. There's a lot of information in there. Again, a link to the final rule with some of those RVU changes with the EP ablation services for this year. Some helpful abbreviations that we find see, or we see commonly documented within our notes in case you need to refer back to those. Again, our MedAxium disclaimer that discusses this is for educational purposes only and does not constitute legal reimbursement coding or business or other advice. We highly recommend you talk to your carriers directly on any policies or procedures or your legal counsel if needed. And with that, that brings us to the end of our webcast and we hope that you found great value in it. And again, if you have any questions, please make sure you get those in the chat box or you can send that to our rcs.medaxium.com email and it will come to the entire revenue cycle team and we'll be happy to help. Thanks everybody.

advanced EP case studies

recent changes in the specialty

common conditions treated

pulmonary vein isolation

atrial tachycardia

SVT ablations

catheters

mapping

radiofrequency energy

intracardiac echo

3D mapping