Hello and welcome to the MedAxium Academy. The session I'll be covering with you today is on EP studies and ablations. My name is Jamie Quimby and I'm a Revenue Cycle Senior Coding Consultant with MedAxium. So I'm a big believer as a coder that understanding the anatomy of a particular area that you're coding is very helpful. When you're trying to apply the coding guidelines but also trying to understand clinically what the physician is doing. So I wanted to go through first before we get into the CPT coding and talk with you about some of the anatomy and applying that to our ablation and EP studies. So we're going to start with the cardiac conduction system. So in the simplest terms the heart is a pump made up of muscle tissue. Like all muscle the heart needs a source of energy and oxygen to function. The heart's pumping action is regulated by an electrical conduction system that coordinates the contraction of the various chambers of the heart. Groups of special cells in the right atrium called nodes send out the heart's electrical signals. The signals then travel along pathways. In the ventricles these pathways are called bundle branches. So how this works the electrical signal begins in the sinoatrial what you will commonly see abbreviated as the SA node. That is located at the top of the right atrium. The SA node is sometimes called the heart's natural pacemaker. This sets the pace of the heartbeat. It starts each beat by releasing a signal telling the atria to squeeze. The atria then passes through the atrioventricle which you might often see that called the AV node. The AV node checks the signal and then sends it through the muscle fibers of the ventricles which then causes them to contract. The SA node sends electrical impulses at a certain rate but your heart rate may still change depending on physical demand, stress, or hormonal factors. So now we're going to look at what some of the arrhythmias and EKGs might look like. So here's a picture of how this all works and looks on a patient that would be getting an EKG performed. So as you can see there's multiple different lines and whether or not that would correlate with that SA node that we were just talking about or that AV node. Again it's ultimately up to your physician to document that interpretation of the EKG would all mean. But this is just kind of a guide to help you understand what some of the lines could mean when you're looking at an EKG strip. Again as coders we're not trained necessarily as clinical. I do know there are some coders that also do have a clinical background but for the most part as a coder we can't just look at an EKG strip and you know say a patient might be an AFib. It would be up to the provider to document that interpretation but again this is just a guide to kind of help you look at what some of those lines might mean if you're looking at an EKG. So again when looking at an actual EKG interpretation, those details will need to be documented and confirmed by the physician. Sometimes they may reference certain phrases in their interpretation and again as coders we might not always know what those phrases mean. So again you might see on an EKG interp where they may say the enlarged R so that could mean that the ventricles might be enlarged. Again flattened T may mean that there could be some cardiac ischemia present and so forth. So again just you want to confirm that with the physician signed interpretation. But again if you see phrases like this this can kind of help you understand what he or she may be saying. So going into what some of the arrhythmias that we commonly see during our EP studies and ablation. So we'll start with what normal sinus rhythm is. So this means that the patient has a normal heartbeat both with respect to the heart rate and rhythm. The heart rate will fall between 60 and 100 beats per minute. Sinus bradycardia. This one can be defined as a sinus rhythm with a resting heart rate of 60 beats per minute or less. This can actually be normal for some patients. So you don't always necessarily code sinus bradycardia as a diagnosis unless the physician has you know talked about its relevance being present. Again sometimes some patients it's just normal for them to be in sinus brady. It doesn't mean they're at any type of risk. They don't always need to have treatment applied to that. So again just verifying that with the physician and how significant that diagnosis would be. You patients again actually become symptomatic until that heart rate would drop to less than 50 beats per minute. So again with that sinus brady it's documented as a rate lower than 60 beats per minute. Again that could be normal. Usually they don't become symptomatic unless it gets under that 50 beats per minute. Sinus tachycardia. We commonly would see this abbreviated as sinus tach or sinus tachy. This is a sinus rhythm with an elevated rate of impulses defined as a rate greater than 100 beats per minute. So a lot of times you may see you know patients coming in for an EP study. The physicians documented sinus tachycardia as your primary indication for this study. So the physician is trying to find out you know during that study how significant that sinus tachycardia is. And what kind of treatment that patient might need to get that you know more stabilized for them. All right now we're getting into some of the more serious ones that really can affect the patient. So a flutter is a condition in which the heart's upper chambers would beat too quickly. It is similar to atrial fib which we'll cover next. But however the rhythm in the atria is more organized and less chaotic than what it would show in an AFib patient. So what that means is the atria will beat regularly but it's beating faster than usual. And more often it's beating quicker than the ventricles are beating. So you'll have the atria is beating quicker and more organized and it's not in sync with the ventricles that are beating. So that's what a flutter would be. There are two types of a flutter. There's typical and atypical. It's really up to the provider to make sure they're detailing that in their report. Again as coders we cannot you know look at a report and know what type of flutter the patient may be in. So that's why it's important for the physician to give that level of specificity if they know it at that time. Atrial fibrillation. This one is one of the more complex and often seen arrhythmias that we see in our EP world. So AFib is an irregular and often rapid heart rate that can increase the patient's risk of stroke, heart failure or other heart related complications. During AFib the patient's, the heart's two upper chambers, the atria, beat chaotically and irregularly. And they're out of coordination with the lower chambers which is the ventricles. AFib symptoms often include heart palpitations, shortness of breath and weakness. There are some people though that are found to be in AFib and they have no symptoms and are completely unaware that they are in AFib. So some patients there are, they are just completely asymptomatic and they have no clue. Other patients have more of those you know symptoms like the palpitations and shortness of breath. Ventricular tachycardia. So we commonly will see this as VTAC or VT. This abnormal electrical signals it causes in the ventricles which cause the heart to beat faster than normal. Usually 100 or more beats a minute and it's out of sync again with the upper chambers which is our atrium. When that happens the heart may not be able to pump enough blood to the body and lungs because the chambers are beating so fast or are out of sync with each other that they don't have time to fill properly. So VTAC is one of the more serious arrhythmias. AFib of course is also a serious arrhythmia because we know that one can cause strokes in patients. So again VTAC is also one of those significant arrhythmias that the physicians do address pretty quickly. Ventricular fibrillation. So typically again you might see this abbreviated as VFib. This is a heart rhythm problem that occurs when the heart beats with rapid erratic electrical impulses. This causes the ventricles to quiver uselessly instead of pumping blood sometimes triggered by a heart attack. VFib causes your blood pressure to plummet and it cuts off the blood supply to the vital organs. VFib does require immediate medical attention and can cause the person to collapse within seconds of developing this arrhythmia. It is the most frequent cause of sudden cardiac death. Emergency treatment includes CPR and shocks to the heart with a device called an automated external defibrillator, that AED device. So again this one is a very serious arrhythmia and typically like I said it has to be addressed very quickly to save the patient's life. All right so now that we've gone through a little bit of what some of that anatomy and arrhythmias kind of look like, now we'll kind of look go into the CPT coding. So now we kind of have the diagnosis clinical understanding a little bit and now we're going to look at the CPT reporting. So we'll start with our EP study. So an EP study is a test that shows how electrical signals move and pathways through the heart. When the pathway is normal your heart will be regular. Of course when it's abnormal then you're going to have an irregular rhythm. During an EP study the heart's electrical signals are recorded. You can see the sensors that are placed with the catheters here. So those sensors in the catheters would then gather information about how the electrical signals are traveling through that patient's heart. The goal of the EP study is to make that irregular heartbeat happen again. That way the provider can measure those electrical signals while the problem is actually happening. The measurements can then show what's causing the problem and help the provider find the spot on the heart that isn't working right. Sometimes they may give medicine through an IV to see if that fixes or helps that irregular heartbeat. Here's what you may see documented in a comprehensive EP study report. In the most typical EP studies three catheters are used. There are times though where you may only see two or maybe four catheters. The most common is the three where they're placing that catheter into that right atrium, the HIS bundle region and then that right ventricle. Again an attempt at arrhythmia induction may be performed. Once this is completed and the sheets are removed the physician report again should show any results of that study along with any recommendations for treatment. These are the two codes available for a comprehensive EP study. You have one code available for induction attempt and then one without an induction attempt. For that 93620 the descriptor states induction or attempted induction of arrhythmia. This sometimes gets asked if the provider attempts to induce that arrhythmia but it's not successful, can I still bill this 93620 or do I have to bill the 93619 since it was not successful? That's not what CPT guidance states. If that attempt was made even though they couldn't get that arrhythmia to show up on the study but that attempt was there, you can still code as the 93620 because the provider did attempt to get that arrhythmia to show up on the study. That's the big difference. Out of the two, the 93620 is the more common one performed. Usually the physician is trying to make that attempt to induce that arrhythmia. Again, I don't see too commonly in the EP world anymore where the 93619 happens but it can. So just again keep that in mind when you're looking at the comprehensive EP studies. Component codes are used in the unusual situation when a full comprehensive EP study is not performed. So in these cases you would only bill the component codes that would be supported in the documentation. Again, sites pasted and recorded within the HART should clearly be indicated in that documentation. These services are multiple procedure reduction exempt so that means no modifier 51 is required if you're only going to report the component codes. These are the component codes available. So again, if they do a comprehensive EP study with an induction attempt, that includes all six of these codes. If they don't perform a full comprehensive study and they're only maybe looking at one section of the HART, then that's when you would use these component codes. So if they're only going to look at the ventricle and they never go into the HIS bundle region or look at that atrium, you would only bill the codes supported for that right ventricle pace and recording. All right, so recording documentation clues. This is a common area because sometimes the providers might not be as specific as we would like them to be as coders. So how would you know if recording was performed? So placing an electrode catheter in a certain location and assessing that electrical activity, that is defined as recording. The data obtained from this portion of the study would include heart rate, rhythm, impulse travel speeds, and then any conduction blocks that they find along the pathway. So if you see any verbiage like that documented in your report, then you know that the recording portion would be supported. And again, depending on if they're doing only component codes or if they did that full comprehensive study, you know, of course, would depend on your coding. But again, that's how you would know if that recording was done, because sometimes the reports are not clear, you know, that HIS bundle recording was done and these are the findings. So again, how you would know that is if you had details, you know, of the findings documented within the report. So applying that, what about pacing? So we have our recording and pacing as our component codes, or again, if you're doing that full comprehensive study, that would include both. So how would you know pacing is performed if the physician doesn't clearly state the word pace? So administering electrical impulses to specific areas is defined as pacing. Pacing allows a physician to test how the various portions of the heart react to those impulses. So for instance, what are the refractory periods? Do those pathways in the heart carry the impulse to the appropriate location? What speed do the various portions of the pathways conduct the impulse? So for pacing documentation clues, again, you might not always see the word pace clearly documented, but there are times where, you know, certain terms may be documented and that would tell us that pacing was performed. So some of the words that you may see is drivetrains is a common one, that extra stimuli, burst pacing. So if you see words like that documented in your study, then you know that pacing was performed. So now we're gonna get into some of the add-on codes for the component codes. So these are for the left. And what I mean by left would be the left atrium or the left ventricle. And these are both add-on codes. For the 93621, that's for the left atrial. Typically, you're gonna see that a catheter was placed into the coronary sinus, or they may abbreviate it CS. This service bundles with all the ablation services now, but if it's performed and supported by documentation, you can report it with a comprehensive EP study, but only with the one with the induction attempt, so that 93620. So again, when we get into the ablation codes itself, that's 93621 will bundle with all of those ablation services. But if the provider's not performing an ablation and they're just doing that diagnostic EP study, again, it could be billed if it's supported with the induction attempt service. For left ventricle pace and record, this one's pretty self-explanatory. Typically, the physician's gonna place that catheter into the left ventricle, and they're gonna do some pacing and recording from that area. There's never any question as far as that goes when they do perform this. It's not as commonly performed, but again, if they do, the report will clearly state that that catheter was in that left ventricle. As far as applying it to what services we can bill it with, so the left ventricle pace and record is reportable with some of the ablation services. It's not reportable with that VTAC ablation, and I'll cover that again later when we get into the ablation details. All right, add-on codes for mapping. So there's two types of mapping services. There's the traditional or 2D mapping is what we typically call, or we have the 3D system. It's important to be familiar with the type of equipment your physician's using. I always highly recommend querying your provider if you need to, to confirm. It also helps build that relationship to where the physician and coder are communicating regularly. There can be times where the mapping, again, may not be clear on the report. Another important note on the mapping services is on the 3D mapping, that is bundled now with all of our ablation services. So the 3D is not billable with any ablation. It's actually part of the ablation procedure. So 2D mapping can still be reportable with some of the ablations, but it's gonna depend on the documentation. You also gotta keep in mind, the 2D mapping is a lesser procedure than the 3D. So if you have 3D performed, there is an NCCI edit with the 2D mapping and the 3D mapping, and the 3D mapping would trump the 2D mapping. So there can be cases though where the physician does not use that 3D map on some cases, and they might only do the 2D mapping. Now, if you have a case like that, you could report the mapping because that 2D mapping does not bundle with our SVT ablation or the pulmonary vein isolation. Again, when we get to those certain or those specific ablations, I'll cover that again in detail. So mapping hints, again, it's important that you understand that type of equipment your physician's using. Many reports, most times they will clearly state 3D mapping, but again, if it doesn't, some common terms and mapping systems that the physicians do use now, you might see CARTO, Insights, another popular one, Inovia. So again, just being familiar with the type of equipment that your provider uses, and just remembering again that that 3D mapping would trump that 2D mapping if both are performed. All right, so there's also add-on code for medication testing that we call. So this CPT code, the 93623, is a program stimulation and pacing after intravenous drug infusion. Again, we typically, in the coding world, call it medication testing. You will see certain medications documented as being given during a study such as Isoprel. Again, although the CPT code 93623 may be reported for that intravenous drug infusion for the diagnostic purposes, if it's only given to confirm the adequacy of an ablation, it won't be separately reportable. I will cover that in more detail later in the presentation. I do have a section at the end where I'll cover what some of those NCCI edits are, and there is one specific to this. So we'll cover that again later in the presentation. So intracardiac echocardiography, we typically call this ICE imaging. This is a separately reportable service, again, with only certain services with the ablations. It's actually bundled in with that pulmonary vein isolation, but can be reportable with the other ablations. So this is typically when a physician does an intravascular ultrasound imaging of the cardiac chambers, and it provides a direct endocardial visualization for the physician. ICE is used to guide placement of mapping and stimulating catheters. During ablation procedures, ICE allows for a precise anatomic localization of the ablation catheter tip in relation to the endocardial structures. So it kind of helps the physician know that they're in the right spot with that tip of the catheter. All right, so now we're gonna get into the ablation procedures. So cardiac ablation is a procedure that can correct the heart rhythm problems or arrhythmias. Cardiac ablation works by scarring or destroying tissue in the heart that triggers or sustains an abnormal heart rhythm. In some cases, cardiac ablation prevents abnormal electrical signals from entering your heart, thus stops the arrhythmia. Cardiac ablation usually uses long flexible tubes, which we call catheters. They insert those through a vein or artery in through the groin and then thread it into the heart to deliver energy in the form of either heat or extreme cold to modify the tissue in the heart that is causing that arrhythmia. So they're either trying to burn that area of the heart to stop that arrhythmia, or they're applying that extreme cold. The first in the series of codes available for our ablations is the AV node ablation. This basically destroys the pathway from the atrium to the ventricle in an effort to create a complete heart block to treat a patient's abnormal rhythm. It may have some components of an EP study performed, but most of the time there is no need to perform a study prior to that AV node ablation. On the AV node ablation, mapping is not allowed as an add-on service for this procedure, as it's considered to be part of the service if it is performed. In the CPT book, if you look under the mapping codes, that 93609 and that 93613, both clearly specify what services you can and can't build them with, and AV node ablation is definitely not one of them. So just keep that in mind. Everything pretty much bundles with an AV node ablation as far as your EP study, any component codes, nothing is separately billable. Normally during these procedures, once they get that complete heart block, which is the primary intent of the AV node ablation, most times they will implant a cardiac pacemaker. So again, that's typically the AV node ablation is not one of the more common ablations performed. So again, if you see that done, typically in most cases, they are going to be implanting that pacemaker, which is separately reportable. The next is the SVT ablation, that 93653. So in this one, rather than destroy the bridge between that atrium and ventricle, as they were doing in that AV node ablation, the physician may destroy one of the pathways through which the electrical impulses can flow. The SVT ablation is a more complex service than that AV node ablation. This does include a comprehensive EP evaluation if it's performed. It does include also that 3D mapping is included and that left atrial pace and record, that 93621 that we were talking about, that is also included. This is actual notes from the CPT book itself, and it references specific CPT codes that cannot be reported with that 93653. So again, this would be performed in any patient that may have an SVT arrhythmia, they may have a flutter, whether it be typical or atypical, they may have atrial tachycardia, those types of arrhythmias fall under this SVT ablation. These are the add-on codes that can be separately reportable if supported. So again, that 2D mapping, again, if you have 3D mapping, you're gonna wanna look at that because that would trump your 2D mapping. You have your intracardiac echocardiogram or that ICE imaging that we were talking about, that left ventricle pace and record, if it's supported in your documentation, you could separately report that also. Medication testing, again, if it's only being given to confirm the adequacy of the ablation that was performed, then you wouldn't be able to report it. It all goes by what's the intent of that medication being administered and what's supported in the documentation. Transseptal puncture, that's separately reportable if supported. And then we have this additional ablation. So the 93655, I'm actually gonna cover this in great detail in a couple of slides up. It's one of the more confusing areas when looking at ablation services. So again, I got multiple slides and we're gonna go through some of what these mean in a couple of slides. All right, our next ablation would be our VT ablation or that ventricular tachycardia. This is the 93654. Again, this also would include a comprehensive EP evaluation if it was needed. CPT instructs that certain services are not reportable, such as mapping, that left ventricle pace and record is included in this. That 93622 would not be separately reportable with this particular ablation. Again, reading the descriptors is helpful. They just updated these. So again, anything that is included in these that they would call bundled would be listed in the descriptors. So here you could see that that 3D mapping is included. The left atrial pace and record is included. Again, our left ventricle pace and record is included. So VT ablation has a little bit more strict guidelines with as far as the bundling goes. Also one thing to note here in CPT guidance with not to report in conjunction with, you'll see that some of the device evaluation codes are included. So if the patient has a pacemaker or a defibrillator and the provider might be looking at the device before they go into the ablation itself, you cannot separately report for those. CPT guidance does state. Medicare also has an NCCI edit. Again, we'll cover those later in the presentation, but the edit will not allow you to override. So that just, again, is telling us we cannot report those device evaluation services with this VT ablation. So these are the add-on codes that can be separately billable with that VT ablation if supported. So again, that intracardiac echo or that ice imaging, transeptal puncture, medication testing, again, depending on intent, and then that additional ablation of a discrete mechanism. So again, we'll cover that in detail in a couple of slides up. All right, our last ablation is our atrial fib or what we commonly call the pulmonary vein isolation. This is the most complex form of all the ablation services. During an AFib ablation, the physician performs a transeptal puncture, which is puncturing through the wall that separates the right atrium and the left atrium. Next, they create a series of approximately 100 ablative lesions that encircle the four pulmonary veins. As with the other ablation services, CPT does instruct that that 93656 cannot be reportable with certain CPT codes. And again, it would include your comprehensive EP study if it's necessary. You can see here in the descriptor. This one also includes that intracardiac 3D mapping. It also includes that intracardiac echocardiography. So that's our ice imaging. So again, reading the descriptors is helpful because it'll tell you what you can and can't report it with. So what can you report separately with our pulmonary vein isolation? So you can report 2D mapping if supported. Again, most pulmonary vein isolations do have the 3D mapping. So again, that 3D mapping is now bundled. But if you have a rare case where the physician doesn't do 3D mapping and they're looking at 2D mapping only, you could report the 2D. Again, medication testing is supportable depending on what the intent is. That left ventricle pace and record is separately reportable. And then we have two separate additional ablation services now. We have the discrete mechanism, which is that 93655. Then there's another one. There's a 93657. And this is an additional ablation to treat AFib remaining after that pulmonary vein isolation is complete. Again, we're gonna go into these in great depth. And with that, we're gonna go into them now. So these are the two add-on ablation services. And again, the most common confusing area when you're trying to figure out if the documentation is supportive and whether or not you can report these additional services. Again, there are two add-on codes, the 93655 and that 93657. The 93655 can be reported with your SVT ablation, your VT ablation, and the pulmonary vein isolation for AFib. Looking at the 93657, this one's only reportable with the 93656, which is that pulmonary vein isolation. So if you have a primary ablation of an SVT, that 93653, you automatically know in that entire case, you cannot apply that 93657, because that is only reportable with your primary ablation of the 93656. So kind of breaking down what these two services mean. So we're gonna cover the 93655 first. So this is a separate mechanism. So when it comes to applying the guidelines, these are actual guidelines that are from the CPT book itself. It states that that primary tachycardia is ablated. During post-ablation testing, a different arrhythmia is identified. That would be considered a separate mechanism of the primary tachycardia. Therefore, you could be supported to report that 93655. They also added additional verbiage on reporting the 93655 with the VT ablation. So here it states code 93655 is listed in conjunction with 93653 when repeated ablation is for treatment of an additional SVT mechanism, and with 93654 when the repeat ablation is for treatment of an additional VT mechanism. So remember that 93654 is the VTAC ablation. So sometimes the provider may identify during a VTAC ablation that there's multiple ventricular tachycardia areas identified and they all are their own separate mechanism of VTAC. So that's what this is saying here. If you have the 93654 as your primary ablation and the provider documents another mechanism of VTAC after they've already ablated that initial, then you could report the 93655 for that additional VTAC mechanism. Okay and then CPT guidelines also do allow reporting the 93655 with that pulmonary vein isolation when an additional non-AFib tachycardia is found. So the key here is in the documentation. CPT again has not given any updates to the 93655 like they have for the 93657. I'm going to cover next with you that 93657. So CPT assistant has come out with some articles in the last few years where they've kind of clarified additional reporting of that 93657. So we're hoping that they'll come out with more clarity on the 93655 with specific examples. So that's what I meant by that when I with there's no further updates from CPT. So all we have right now is what is in the CPT guidelines from the book. Again the 93655 is specific to a separate mechanism. So if you have a patient coming in for an SVT ablation, the area where the SVT was you know physician successfully ablated and then they continue doing testing throughout the heart, they find a non-SVT arrhythmia such as maybe the patients in typical a-flutter now and they find that in a different area of the heart, you now have a separate mechanism of an arrhythmia. So if they ablate that area then that's where you can build that 93655 for that separate mechanism. All right so now we got the 93657 so remember this is only separately reportable with the pulmonary vein isolation for AFib with the 93656. The key here is that once the pulmonary vein isolation is achieved, attempts either re-induction of AFib, identify an additional area of AFib, then that in that physician document or they ablate that area then that's when you can ablate. So key here is that pulmonary vein isolation has to be documented as being complete before you can start looking at building these separate mechanisms for that service. This is the first CPT assistant article that was updated and released on that 93657. This one was released back in September of 2019. So the question that was asked was would it be appropriate to report the 93657 if the physician documents complex fractionated atrial electrograms which you commonly will see called cafe lesions. So if the provider documents those cafe lesions post-pulmonary vein isolation ablation and there is no evidence that the patient's in AFib but they have those lesions present, can you build the 93657? CPT came back and said yes. So this was a positive clarification for reporting. So again what they are saying is once that pulmonary vein isolation is complete and during the post-testing the provider identifies those cafe lesions and they ablate that area you can still report the 93657 even if the patient is not in AFib any further. So again you have an abnormal area where that's showing abnormal signals in the heart post-pulmonary vein isolation and then the provider does additional ablations then you can bill it. So this was a good clarification that they released a couple years ago. Second one was released back in November of 2020. So in this one the question was asked would it be appropriate to report the 93657 for a patient that has persistent AFib if additional ablation lines are performed post-pulmonary vein isolation with no further AFib being present or those complex fractionated or cafe lesions being present. So CPT came back and said yes and this was actually a surprising clarification but again another good one. So yes you can report it. The guidance does state though that the patient has to either have documented proximal or persistent AFib and whether they are in AFib or sinus rhythm at the time of treatment the provider performs that additional ablation line such as a roof line you can report this service now. But another area to note with this there has to be documented medical necessity still. So the provider can't just state post-pulmonary vein isolation I did a roof line. Well why did you do the roof line? So what this further states in the clarification is there should be some mention of fractionated potentials or linear lesions being present to be supportive of that additional roof line for example. So again you have to have medical necessity but here the patient does not have to be in AFib or have those cafe lesions present but again there should be some kind of abnormal fractionated potentials or lesions present that would support that ablation needing to be performed. So again another good clarification. One thing to point out too with these additional ablation services they have an MUE assignment which is a medically unlikely edit and this can be found from Medicare's website. They assign this MUE to each CPT code. So the MUE assignment for the 93655 and that 93657 is two units. So if you have a pulmonary vein isolation being performed as your primary that's the 93656. Provider documents cafe lesions and then maybe in a different area they document some fractionated potentials. So now you have the 93657 supported twice because you had two different areas but say the patient also ends up going into an atrial tachycardia and then maybe they also go into typical a flutter in two separate areas of the heart and they ablate those two areas also. Now you have the 93655 supported twice too. So again documentation is very important from the physician and kind of painting that picture of what they're doing why they're doing it and then that kind of helps guide us as coders of how how much can we bill of that. So again keep that in mind those additional ablations can be reported up to two times per encounter. So again if you have a case where you have that pulmonary vein isolation and you know there are there are times where you could build those additional ablations the two two times. So you technically you're billing five ablations because you have your primary and then the two additionals for your AFib and then your non-AFib. So just again stress that documentation is so important. All right I know I've mentioned a few times during the presentation about NCCI edits. So what that is is the National Correct Coding Initiative. This again can be found on Medicare's website. They have a manual that they update every year and then they release edits with certain CPT codes and they tell you whether or not they have an edit assigned to them and if you can override that edit with the modifier. So again you can find all that detail on Medicare's website. I wanted to point out some that are relevant to the EP studies and ablations and some frequently commonly asked questions that I get from physicians on whether or not they can report a certain service. So first one I want to cover is ultrasound guidance. Again this is not separately billable per Medicare NCCI manual. This is language that's from the manual itself. There is no modifier that is allowed to override the edit. So if you ever see your provider performing that ultrasound guidance to place those catheters and obtain access, the edit specifically references all of our EP services. So you can see 33202 through the 33249 that starts with our cardiac pacemakers and ends with our cardiac defibrillator implants. So every service in between that 33202 through the 33249 is not allowed to report ultrasound guidance with. Same thing with our EP studies and ablations. The 93600 is our component code for his bundle recording and it goes all the way to the 93662. So any CPT code within that range is not separate. You can't build the ultrasound guidance with. So that includes all of our EP studies and ablation procedures. Next edit that's in place is the arterial cath or what we might call an art line. It does bundle with your global surgery package, even a zero day service like our EP studies and ablations would fall under. They are considered part of the main procedure. It is common to see during an EP ablation procedure, the provider placed that art line at the start of the case. This is to help monitor the patient during the study. So because it is related, it cannot be separately reportable. Now, if you have a rare case where that documentation shows it's unrelated to the EP procedure being performed, then a modifier is allowed to override that edit. It is very rare, though, that you will see that documented as unrelated for your EP studies and ablations. All right, cardioversion, this is another big one that I get. So can you build cardioversion with your EP studies or ablations? So again, there is an NCCI edit in place with reporting the service. You are allowed to override that edit with a modifier, but documentation has to support that medical necessity. One big thing to point out with our cardioversions, the most common one that we in our EP world see is the external, the 92960. Big thing about these services is they are considered elective procedures. So what that means is it has to be known that it was going to be needed and it has to be placed in the order of the procedure being scheduled and performed. So if the provider has started any portion of the study, the EP study or ablation, this was not documented as an elective cardioversion. They've already started their EP study and ablation and the patient's in an unstable arrhythmia that they have to get the patient stabilized to finish the procedure. So they go ahead and cardiovert the patient, it's bundled then. So the only time that it wouldn't be bundled is if it was known it was needed before the provider starts the EP study or ablation, they go ahead and cardiovert that patient before they start, then you could bill it. Again though, documentation is so important here because these are considered elective. So you would have to have an active order for it just like you have your active order for your, you know, EP study and ablation that's being performed. It would be the same thing for the cardioversion. It would have to be known that it was needed and it would have to be performed before they start any portion of the EP study or ablation. All right, here's that medication testing. So again, this is language from the actual NCCI manual on that 93623. So again, just to highlight, they state if it's performed following that ablation procedure to confirm that that ablation was successful, can't report the 93623. If it's performed for diagnostic purposes, you know, and they're trying to induce a non, you know, a separate mechanism of an arrhythmia, then you could report it. So again, it goes by intent and that medical necessity of the procedure. So most times I do see them performing it post ablation, but they're looking for a separate mechanism of an arrhythmia. So again, just key to that documentation is very important. Last edit is our periprocedural device evaluations and programming. So you have one code for a pacemaker, the 93286, and then one for a defibrillator, 93287. So a periprocedural device evaluation and programming, what that means is before procedure starts, the physician is going to evaluate that patient's device. They're going to make any programming changes necessary. For that patient to have a successful procedure, typically post-procedure, once they finished, they go back and re-evaluate the device and change the programming back to the original settings or to a more suitable setting for that patient needed. Now, when looking at the NCCI edits, so if you're applying these two services, whether the patient would have a pacemaker or defibrillator, the edit in place does bundle with our VT ablation, the 93654, and that 93656 for the pulmonary vein isolation. And no modifier is allowed to override that edit. So if you have a device evaluation happening during one of these two ablations, you can't bill for it. The edit will not allow a modifier to override it. So it's considered part of the procedure. But with our SVT ablation, the 93653, these services do not bundle. So if the patient has a pacemaker and before the provider starts, you know, doing the SVT ablation procedure, they evaluate that system and do changes to it, they can bill for it with just the SVT ablation. Here's some helpful abbreviations, because a lot of times when we're looking at reports, we will see words abbreviated and not often, you know, spelled out for us. So again, this is just help. These are part of some of the EP study services, so that your HIS bundle, your right atrium, right ventricle, and again, that coronary sinus, which oftentimes is used to paste that left atrium. They should be specific with that though. You can't just assume with the coronary sinus that they're doing left atrial paste and record. The report should clearly show that that's what its intent was. Again, some other helpful abbreviations includes, you will typically see these findings documented in an EP study portion, not so much, you know, your ablation, but it's during the diagnostic portion of the EP study. You may see measurements and abbreviated words in the actual findings. So this is just to kind of help guide you with what, you know, an AH measurement might look like. It's typically, it's when the HIS catheter record is doing electrical signal recordings from that high right atrium. Your HV measurements would be from, oh that's a typo right there, that should say high right ventricle catheter right there. So that, this is just again to kind of help guide you on what those abbreviations might mean. Again, more helpful abbreviation clues. Again, this a lot of time would be documented. It could be with an EKG or it could be part of your diagnostic EP study. All right. And with that, that brings us to the end of this section. I hope that this has been very helpful. If you have any questions, please feel free to reach out. Here is our email directly and it'll come to our department and we'll be happy to help answer any questions you have.

Jamie Quimby

EP studies

ablations

cardiac conduction system

arrhythmias

CPT coding

documentation requirements

billing regulations

EP study reports