Good afternoon everyone, we're going to wait just about a minute or so and let people get registered that are registered have a second to get jumped on the webcast. Good afternoon. If you're just joining us, we're just going to give it about another 30 seconds or so and give folks a moment to jump on the presentation here. All right, we'll go ahead and get started. Good afternoon, everybody, and thank you for joining us for our third session for our bootcamp week. Today, we're going to cover Advanced EP Case Studies. My name is Jamie Quimby. I'm the Director of Coding here with our Revenue Cycle Department at MedAxiom. If you are new to coding EP services, this webcast is probably going to feel a little overwhelming. It is very case study driven. I did do an EP series this year, and those webcasts can be found on our MedAxiom Academy platform. We did offer those as an on-demand option. If you are in need of CEUs, you can listen to that presentation and take a 15-question quiz, and you will still be able to obtain your one-and-a-half CEUs if you do need those. I did, in the series, cover EP extensively from a basic just learning it standpoint. We covered devices, we covered ablations in EP studies and we also covered the monitoring services. This is an extension to that series that we did this year, and this one though is going to be more advanced. I will plan to do another advanced session next year, just because I get a lot of questions sent to me from members, and I've had tons of questions on device cases this year. A lot of the cases are going to be geared towards that area of EP. There are some ablations, however, but next year my plan is to do an advanced session and focus on the EP ablation services. Just a couple of housekeeping slides. If you are new to our platform here, you can access a copy of the slides from the chat feature. There is a link and it will take you to a PDF download. Some people do have issues with the link, so if you just pop into the questions box, the Q&A, and say you're having issues, then one of our support members will help you get a copy of the presentation. If you do have questions relevant to today's topic, please type those in the Q&A box as well. Then at the end, we'll try to take as many questions as we can. We do have about 80 slides to cover today, and I do have 10 case examples, so we will definitely do our best to keep on time. But the questions can be compiled at the end, and we do put that document on our MedAx Academy platform. All right, so CEUs, you can download these directly from your MedAx Academy login. Please do give our team at least one to two business days to get those uploaded to your account. But when you do log in and see that, you can claim it. This next slide shows you how to claim it, so if you're new to doing that, you would just log into your account, log into that particular, on your MedAx MyAcademy, go to that particular webcast, and then when you click on it, you have another box that pops up that says Claim CEU, and you have the option to either download it directly to your computer or print it. All right, we're just going to highlight, you know, maybe 10 or so slides of stuff that I've already covered this year in the series, but definitely want to point out because it's going to be pertinent to some of the cases that we covered today together. So first, this was a revision that we covered on Monday session. It's had a lot of traction and questions about it. So this was a revision by the AMA in your CPT book. It's just revised text, and the key is down here at the bottom. They talk about when a portion of the EP study cannot be performed, whether it be just one or more components, it was added that the provider should document the reason why they could not perform that. There's nothing in the guidance that states we have to reduce the service. Prior to them doing this new revision, it just said when clinically indicated. So again, I wouldn't change anything with what you're doing. Just educate your providers that this phrase was revised and just let them know if they're not able to perform a component of the complete EP study, they just need to indicate why they could not perform it. That's all they have to do. All right, and this is a slide that I put together when they did all the bundles. It's just something that's helpful to us coders. It kind of breaks down what is automatically inherent to the procedure, what is bundled and what is not bundled, so meaning you could separately report those services. So again, it just breaks down the different type, our complete EP study with induction attempt, your SVT, your VT and your pulmonary vein ablations. So again, just a helpful resource. And this is my favorite anatomy photo, and I'm happy to share it with everybody. It really explains the anatomy of when you're looking at the ablation services, what part of the heart they're in and where they're at with the ablations. The one thing I want to point out here, so here you can see you have your pulmonary vein isolation. So here's your pulmonary veins. We're going to have case examples today with this. So there is a posterior wall. This is what is here. So sometimes when they do an ablation, they do what's called a box ablation. What the box ablation is, you see this little box right here. That is what they are referring to. So up here is your roof line. In the middle here, you have your inferior line. And then at the bottom here, you have your floor line. So we have a couple cases today. One is they specifically referenced doing a box ablation, meaning they did two lines. So sometimes I get questions, well, what if they do a roof line and a floor line? Can I bill the additional ablation twice? It's going to depend on your documentation. Okay, so I have two cases at the end that we're going to go through. One of the cases, I can only report one of the additional ablations. On the other case, I'm able to report two. So when we get to those, I'm going to break those down. And as we talk through the cases and the documentation, I'll explain to you the difference between the two. But this picture here gives a perfect, you know, image of what that box ablation looks like, okay? So just keep that in mind. And then another common one that we see during a pulmonary vein isolation, a lot of times they will also do what they call a CTI ablation, which is the cavo-tricuspid line. And that's done for typical flutter. So again, it just kind of shows you where that is located. So again, just all very helpful. So wanted to share this with you guys because I personally love it myself for coding EP. All right, so briefly, we're just going to cover the additional ablation code. So, you know, we have two options. We have the 93655 and the 93657. The 55 is when an additional discrete mechanism is present after you've completed your primary ablation, and they go ahead and ablate that additional mechanism. This is reportable with your SVT, your VT, and your pulmonary vein isolation ablation codes. You can report it up to two times. With the MUE table, both services have a MUE assignment of two. You could try to report more with obviously an appeal because the carrier is going to deny. And, you know, and what I have some practices that I work with right now where the provider's documentation is very good and they want to report the additional ablations. So they are currently under the appeals process. So I'm interested just to see how those process after the carrier reviews the documentation, you know, and that'll kind of help the provider decide, is it going to be worth continuing to report the additionals over the assigned MUE of two, or do we want to, you know, just keep appealing them or just report the, just the maximum of the two units? So again, if any of you are out there reporting more than the two and having success, I would definitely love to hear from you and, you know, just see how that's going for you. But currently the MUE assignment is two, but you can appeal. Same with the 93657. This is for an additional ablation after the pulmonary vein isolation is completed and it's for the treatment of AFib remaining. And that is only reportable with the 93656. But again, you can report it up to two times if supported. And this is actual language in your CPT book. It just breaks down that separate mechanism and how they define it. So in the first category here, this is being applied to an SVT ablation. So in the example, they say the primary tachycardia that was ablated was the AV nodal tachycardia. And during post ablation testing, they had a separate atrial tachycardia or atrial flutter or an accessory pathway. You may see that documented as well, but that was identified. That would be considered a separate mechanism from the primary tachycardia. In the second one, they refer to treatment of additional VTAC mechanism. So again, it was done with an SVT ablation or it could be done with the VTAC ablation, but an additional mechanism of that VTAC is present. And then again, of course, we're going to have case examples with this. Code 93655 can be reported with the pulmonary vein isolation when an additional non-atrial fib tachycardia is separately diagnosed after that pulmonary vein isolation is complete. And again, we'll have case examples to show that at the end. Next three slides are going to be from CPT Assistant, and these are all referenced to the 93657. So the first one was released back in September of 2019, and this was kind of really when the door opened for helping clear some of that gray area up with reporting this additional ablation after the pulmonary veins are ablated. So in the question it asks, is it appropriate to report the 93657 when the complex fractionated atrial electrograms, which we commonly call as CAFE lesions or a CAFE ablation? So they're asking, is it appropriate to bill that additional ablation for the CAFE lesions being present? And what the AMA said is, yes, it is supported. Even if the patient is not in AFib, but those abnormal lesions are present and you ablate them, that is separately reportable. So that was definitely a good clarification we got back in 2019. And then the next year they gave more clarifications. So another question, is it appropriate to report the 93657 for a patient with a clinical diagnosis of persistent AFib if additional ablative lines are performed post-pulmonary vein isolation, and if the patient is not in AFib during the encounter and the procedures are not those complex fractionated atrial electrograms? What they stated here is, yes, you can report that additionally. But the key here is that it says can be performed in patients diagnosed with either proximal or persistent AFib, whether they're in that fibrillation or sinus rhythm at the time of treatment, but they still have to document medical necessity. So they should at least mention that there's fractionated potentials or linear lesions present or even the CAFE lesions. There has to still be medical necessity. They can't just go into another part of the heart after they've done the PVI and say, I wanna go ahead and ablate here. There has to be a reason why. So yeah, they don't have to necessarily be in AFib, but what is abnormal in that part of the heart to justify you doing that additional ablation? So just keep that in mind that there still has to be medical necessity. And then this last one, this is an older one from July of 2013, but in this question, it's being asked, what is considered your primary ablation in a sense? So what if you have a patient that's coming in with a known history of AFib and AFlutter? So at that point, what is your primary ablation and do those arrhythmias need to be present? So if the patient has that clinical arrhythmia documented and they are addressing it and treating it ongoing, doesn't matter the order. You're gonna report it at the highest ablation code. So obviously your pulmonary vein isolation is gonna be at the top. So you may have times where both diagnoses are documented in the patient's clinical chart. They are being addressed and treated. Provider knows at the start of the study, their intent is to treat both arrhythmias during the ablation. And meaning that a lot of times, they know they're gonna go in and do a pulmonary vein isolation for the AFib, but they also know they're gonna do that CTI line for the flutter. So what this is saying is, as long as the clinical arrhythmia is documented in the patient's chart, it doesn't matter the order of when the ablations are done, you're still gonna report your highest one first. So they could do the CTI line first and then go into the pulmonary veins and do that. You would still report your primary code as your pulmonary vein isolation. And then your CTI line would be your additional separate mechanism. All right, so some device service highlights. I am getting tons of questions from folks and they're all very good, valid questions. So we had some leadless pacemaker systems added last year. And so we have all these coding options. So I actually put this together when I was putting this presentation together, because I can't even keep my head wrapped around of all the different codes. So I have all these cheat sheets and Post-it notes all over my desk. And I was like, I need something that's easier to read. So I put this together, hope everybody can find some use for it, but it kind of just breaks down whether it's a new insertion, insert or replace, removal or removal and replace. So they kind of didn't do this, thought out that great in my opinion. So with our existing code for a single RV leadless system, for a new insertion or replacement, it's the 33274. If they remove it, it's 323275. These two NCCI together, you can't override the edit. So if they do a removal, meaning they're inserting a new system and taking the old one out because the battery needs to be replaced, you would just report this 33274. You get to our newer codes that are category three still, these are different. So we have a remote, so these are basically the battery change out codes, if for these newer category three codes. So a little bit different category here. But insert, you have your insertions, your removals, and then your removal and replacements. So again, I needed something for myself. So definitely wanted to share it with our MedAxium members as well, just as a little resource guide there. And then another one I put together that is helpful as well is the clinical trial numbers because there are so many out there. And I actually have a question in here right now. It's asking, is the 33274 still experimental? That is going to depend on your region. I do know we work with some members now where their area still requires the Q0 with the clinical trial number on it. But I do know other areas do not require it. So check with your carriers. See what their policies are. Medicare does still have the NCD out for these, but in their NCD for the RV leadless system, it still references that category three code, which we obviously know is old because we have a permanent category one code now for that service. So just check with your payers is my best advice and see if they're still actively participating in the clinical trials. If not, then you don't have to worry about the Q0 and all that fun stuff. If they are though. So there are more clinical trial numbers than what I put on the slide. These are just the main active ones that I found. But if you go to this link on the slide at the bottom here, that will take you to all of them. I think there's a total of nine that are active right now, but some are older. So they're not, not everybody's still participating in them. So again, these are more of the newer ones that I found. So wanted to share that with you guys too. Because as I need cheat sheets, wanted to share with all of our members. All right, this is another hot topic. His or left bundle branch lead. So there is limited information on these obviously. Is there a code needed? Yes, definitely need a code, but do we have one yet? No, we don't. So current guidance right now is to code to the placement of where the lead is placed. So in this diagram, you can see it breaks down where those areas are in the heart. So you can see like down here is our LV, which is where your coronary sinus is located down here. And you know, for the add-on code, for the LV lead, it has to be placed in the cardiac venous system. So when you got a left bundle branch lead, that's going to be located up here. Your His bundle is up here. So almost always when I see these implanted from the electrophysiologist in their note, they almost always reference the RV septum. So you're going to code the lead placement to the chamber of the heart that's being placed, okay? So if you have the left bundle and they referencing it's placed in the RV septum, what you have is an RV lead, okay? So again, it's just going to depend on your documentation. Our current recommendation is to code to the lead placement. I do know there's some programs out there that are trying to report this with an unlisted code. I do not know if they're having any success with that. So again, I don't want to say we are recommending that. If you want to try to report them unlisted and see if you have any success with that, then by all means, go ahead and try if that's a decision your practice makes. Like I said, our current recommendations is to code it to the lead placement itself. So again, if you're placing it in the RV septum, that is placed in the RV chamber still, okay? Another question, when they do place a HIS bundle lead, a lot of times they're doing, they document it and it makes it look like they're doing the HIS recording, which is part of that EP component study. But when they're doing it, they're actually doing it kind of like a venogram where they're looking for the appropriate position to place the lead. They're not doing it as a diagnostic for an arrhythmia. So if you do see that HIS recording being done during placement of the lead, just know that's to help aid in the lead placement itself. So it's considered roadmapping and not separately billable. All right, and then that brings us to our venograms. So almost always when you're looking at a device implant, a lot of times they are doing a venogram. A lot of times, like I said, it's done to help place the lead. So it's not being done for diagnostic purposes. Now, I do have a case today where they did a venogram and it does show that there's an occlusion, but we're gonna talk through that case together because I did not have a reason as to why they were performing it other than placing that lead. So we'll talk through that case when we get to that part of the presentation though but again venograms when they are done they can be built separately if it is done for diagnostic purposes so if the patient has symptoms and the provider wants to you know investigate if it's even possible to place a lead due to the patient having symptoms that is considered diagnostic that at that point but when they just go in and do the venogram as they're going into the different chambers of the heart making sure that they have an appropriate you know spacing and sensing function to place the lead itself that's considered road mapping. All right so just a few NCCI edit reminders for EP. We cannot ever ever ever build ultrasound guidance unfortunately this is actual printed language in the Medicare NCCI manual so you can see I reference the specific chapter in the section it is you can see how they specifically state and see how wonderful they are they even list the code ranges so we have all of our device implants all of our EP studies and ablations they reference those specific codes and state here ultrasound guidance is not separately reportable so they do ultrasound guidance a lot on these cases of course because a lot of times especially with ablations and EP studies they're placing multiple catheters but unfortunately they're not ever billable so I just wanted to make sure everybody knows that. Arterial lines a lot of times they place these as well these are a separate procedure designation so there has to be a separate reason and it being done that it making it not associated with procedure they're performing and I do have a case where they do place one and it is to help aid them during their procedural service they're performing so again we wouldn't separately bill it in that case because it's not meeting that separate procedure designation. Cardioversion I think I saw a question pop up in the questions about this one so there is an NCCI edit with cardioversion when you're looking at your ablation services so big thing to remember here cardioversion is an elective procedure there has to be order and consent for this service to be performed if it's done in an emergent situation you cannot bill it doesn't matter what scenario you're in it's an elective procedure so keep that in mind has to have consent for it so if they consent to it so say the provider knows the patient's been you know in and out of their AFib it's uncontrolled they're already expecting the patient to be in AFib at the start of the case they're going to go ahead and ablate it before there they start the ablation and the EP study patient consents for it that's totally fine you can bill it in that case as long as they do the cardioversion at the start of the case once they start any portion of the EP study and ablation it's no longer billable because if they put that patient in that arrhythmia they have to get them out of the arrhythmia you know as safely as they can so there are times where you see that the provider does the ablation the patient's AFib just keeps persisting and you know ablation is not terminating it so a lot of times at the end they'll go ahead and cardiovert the patient to get them out of the AFib so in that kind of scenario you can't bill for it but like I said and we do have a case one of my cases it does have an elective cardioversion done with the ablation so we'll I'll show you what the good documentation looks like for that but you know like I said if you have good documentation provider intends on doing this at the start of the case you have your consent in your order for it you can bill for it it will need a modifier 59 or an X modifier if that's what your carrier prefers because it will bundle with your ablation being performed. Reminder on NCCI edit with the medication testing this does have to be done for diagnostic purposes if it's done at the end of an ablation to confirm the adequacy of the ablation it is not separately billable at that point and I do have a couple cases again at the end where one's billable one is not so we'll cover that in detail as well. And then periprocedural device evaluations when you're looking at an ablation service these do bundle with two of our ablations that is our VTAC and our pulmonary vein so if you do a periprocedural service for any to one of those two ablations you cannot bill the periprocedural programming it is bundled there's no modifier that allows you to override that edit but if you're doing an AV node ablation or an SVT ablation those do not bundle so you can bill for those if they do a periprocedural device evaluation so again keep that in mind. And then let's get into our case studies because we have ten to cover today and we have about an hour left so let's go through these in detail this is going to be very heavy towards device implants but like I said I've been getting a lot of questions on the pacemakers especially the leadless so I do have several cases for that and at the end I think we have three cases with the ablation so again next year I will plan for an another advanced session and that one will be primarily focused on ablation cases because I know that's always a hot topic. All right so this one is a left bundle branch lead case this patient recently had open heart surgery that was complicated by the patient going into complete heart block which required them to get a dual chamber pacemaker system they also ended up getting the epicardial pacing wires the patient's recently placed left bundle branch lead has dislodged so therefore they're bringing the patient back to the EP lab to address that dislodged lead and I can tell you from talking with EP providers across the country there are some that are not huge fans of the left bundle branch lead I've had one tell me personally that the leads are not made to stretch that far and they do happen to dislodge a lot and as I code EP on a daily basis for multiple practices that we work with I do see this commonly so this unfortunately this is a common thing I see I do hope that the vendors you know look at this and maybe you know do whatever they need to do so that these leads are stretched being able to be stretched further so they don't dislodge a lot but this is another scenario that I see a lot so this one dislodged so down here in it this is just them attaining the consent and all that good stuff sedation was administered by the anesthesiologist so we don't have any moderate sedation to worry about and then this is them opening up that pocket so that's the prior incision for the pacemaker generator pocket that they opened then here they go ahead and get the capsule open here again this is just standard phrase where they're getting that generator and the leads freed they go ahead and disconnect everything and then they inspect the pocket make sure they do anything to stop any bleeding that's going on and then down here they start analyzing the leads that are in place and testing them here you can see that they're placing an active fixation lead it was advanced under fluoroscopic guidance to the RV apex where they found appropriate sensing and pacing thresholds so they're going to go ahead and suture that one in place and then down here is where they're going to place another one they're gonna go through they're using a his delete lead delivery system they advanced it through the right atrium and they're going to keep you know going further down you can see here they then place the lead are they're using the his bundle it was mapped as a reference point to help guide and that left bundle branch pacing the sheath and the lead were advanced along the ventricular septum fluoroscopy confirmed that the lead was septally direct the lead was rapidly torqued into the ventricular septum and then they're doing the pacing and sensing I'm trying to get the appropriate measurements that they need to go ahead and place that lead permanently if they do confirm left bundle branch pacing was confirmed with the presence of a right bundle branch block and then they go ahead and secure that in there and then the old dislodged lead was removed without any difficulty so now we have an implant of two leads and a removal of one and then it says the down here the leads were attached to the new pulse generator so they took out the existing one that that was placed and put in a new one it looks like and then go ahead and wrap up the case here so a lot of times in a device report you're gonna have details like this at the bottom of your report where they detail the model of the you know the model the vendor sometimes they detail the status of it where it's explanted or implanted so this one the original implant was done on October 15th it was the next day that they found the left bundle branch lead had already dislodged so that obviously not something they expect to happen especially within 24 hours so this one obviously we're in the 90-day global from the original implant but was not you know something that was planned also for them to have to bring the patient back that quickly so you can see here they detail out the placement of where these are located so you have your generator up here so this was our existing one and then they replaced it during this session it's in the left pectoral and then here's our lead placement so we had a right atrial lead that was placed the day prior they reuse that lead so that one's still implanted this was the lead that they removed it was placed in the proximal RV septum that would have been the left bundle branch lead that dislodged and these are our two new leads so we got the RV apex that was the first lead they placed and then they did the second one through that his and then down into the left bundle and again provider references the RV septum and then again all the different measurements with the sensing thresholds all that all that good stuff is documented and then again just in the conclusion successful removal of our old left bundle branch lead that dislodged with placement of a new left bundle branch lead successful placement of the RV backup lead and then they replaced that generator so our original device done the day prior just had the right atrial and the left bundle branch lead so now with this system they have the right atrial the right ventricle and the left bundle through the RV septum so we have three leads but two that are in the RV chamber so final coding for this case 3 3 2 3 3 for removal of that generator obviously 78s needed this was not a planned expected thing during that 90 day global of the original implant 3 3 2 3 4 with the 78 for the removal of that dislodged left bundle branch lead and then what we ended up in planning is a new generator and two new RV leads so we have 3 3 2 0 7 78 KX modifier because we had that history of the need for the pacemaker system to begin with is for that complete heart block after that open heart surgery and then again the T code is for that dislodged lead all right so case 2 this is a new ICD system with a failed LV lead implant this case was actually posted I think last week on our listserv and it had a lot of back-and-forth with it I thought it was an excellent case so thought I would take the opportunity to add it so we can all discuss it at you know and review it together and see what coding is supported at the end so with this one procedure performed meaning the intent is by ventricular defibrillator implant with they ended up doing a successful left bundle branch pacing they did try to place a coronary sinus lead though our indications we have non ischemic cardiomyopathy chronic systolic heart failure label as class 3 stage C and then they have a left bundle branch block as well so here you can see a left upper extremity venogram was performed to help venous anatomy for access so this is not done for diagnostic purposes this is done to help place our leads so this is a perfect example you're definitely not going to report the venogram and then you can see here there there's it did show no signs of obstruction so that's great but again patient wasn't complaining of any symptoms and it shows that they're doing the whole venogram to help place the leads so and then down here they're using an ultrasound machine but guess what we can't build ultrasound for any of our EP cases so I didn't even highlight that one they did create your pocket typically with a new device implant it's pretty standard to see them come create the pocket first and then they go and place the leads after that there are times though where they may go ahead and get the leads in place first and then at the end create the pocket but doesn't matter the order just typically because I code these every single day I tend to just see the pockets created first you can see the venous sheath was then inserted over the wires they didn't go ahead and place the defibrillation lead it was advanced to the right ventricle and then it's placed in the right ventricle lower septum they got appropriate sensing capture threshold all that good stuff and now they're gonna go in and they're gonna try to place that coronary sinus lead here you can see they're using contrast to verify its location they were able to advance the sheath and sorry I clicked too fast they were able to advance the sheath into the coronary sinus and then through that sheath they place the pacing lead through that to advance it they did initially find thresholds acceptable but on retracting the sheath the it says it retracted back into the coronary sinus multiple attempts were made at getting back into that area where they were finding the appropriate thresholds but they they were successful but they were not able to advance the sheath so it states after multiple attempts and trying multiple catheters and wires they then decided to go ahead and proceed with the left bundle branch so they did actually try to place the lead right here but they were not able to get back to the area they found the adequate thresholds and the captures to secure the lead in place so they ended up having to abort that and then go ahead and just switch to left bundle branch pacing so that's what they do down here again they get the sheath into place advance it into the right ventricle and position it within the septum they then advance the pacing was performed it appeared to be appropriate so the lead was advanced into the septum the lead was interrogated and demonstrated adequate sensing and pacing the sheath was then slit and the lead was then sutured into place to secure it and then finally the third wire they implant that right atrial lead in the right atrial appendage and then they go ahead and secure that into place at the end they connect the leads to the new Abbott defibrillator generator and they get all that placed within the pocket and close the patient up so here we have three three two four nine for our new defibrillator system with our new atrial lead and we did end up with two RV leads they did attempt the coronary sinus leads so still want to report it but we're going to reduce it with the 52 because it was not successful but you still want to give the provider credit for the attempt and then these are the diagnoses that we would end up with based on the clinical indications documented so that was an excellent case so I was glad it got posted so we could cover it all right let's cover some leadless implants so this one's pretty basic you know they tend to at the start of the case they'll define the type of leadless system that you're working with indications they have documented non-reversible symptomatic bradycardia due to that third degree AV block here we're just getting consent again anesthesia was present to give the conscious sedation so our provider is not going to be billing for that here again they're just getting their wires and all that set into place then they're going to advance the device they are going to advance it through the high right atrium down into the right ventricle and then they're going to turn it until they find appropriate sensing and reading and then you can see here they're going to deploy it in that mid distal septal septum and they're going to obtain those thresholds they did a pull test which revealed good position so again they're going to secure that down in sight and basically wrap the case up here so this one's pretty straightforward so we have it was placed in the RV so we have three three two seven four again if your area still participates in the clinical trials you want to get your q0 on there and if you're appending your q0 you have to have your secondary diagnosis of your z00.6 and then of course you would report the applicable clinical trial number as well. All right case four is a dual chamber leadless implant so this is a new system this patient has symptomatic bradycardia due to the sick sinus syndrome they have documented sinus pauses on a zeo patch monitor and a telemetry so here again anesthesiology is going to be involved to do the moderate sedation again we have ultrasound guidance but we can't bill for it and then they're talking about the closure device they're going to use at the end so when you see closure devices used these are not separately billable by the provider if you're billing for the facility there is a C code it's C 1760 and that is separately billable by the facility most do list it as an n1 status meaning the reimbursement is going to be bundled in with the primary service being performed so there might not necessarily see any additional reimbursement pertain to that but you can separately report it on the facility side but for physician reporting you know if they open the patient they have to close them essentially is the deal so um you know can't bill for it separately for the provider. All right so here they do talk about going on the ventricle side first so you can see they advance the AV or VR device they get it prepped and then you can see the delivery system was advanced and then on our next slide it does initially after multiple attempts and in various positions along the septum they were not able to well they do deploy the device but then they have issues with it so down here they talk about how they had to they were concerned about the risk of future dislodgement so what they ended up doing was unscrewing and removing this original device and then they did a new delivery system so they basically started back started over from scratch to re-implant a new RV system into that patient here so once they had adequate capture and sensing measurements they go ahead and release that device into the ventricle now they're going to move on to the atrial leadless system. So again they're going to deploy the device. They're going to advance it. Again this is just them moving it through that area of the heart, repositioning it multiple times to get that adequate capture. So once they have that they go ahead and release the device into that part of the heart. So and then here we're just wrapping up the case and removing all the catheters and all that stuff. So here and then this is just a snapshot that was in the op report of the hardware and all that that was implanted. So you can see this one's an AVIT and you can see that they did place the leadless systems in the RA and the RV. And here's all of our final pacing and thresholds and all that good stuff. So then what we end up here is a 0795T with the Q0 and then of course our 6 sinus syndrome and our clinical trial. And again you would add the applicable clinical trial number. I didn't add those to these cases. I did give that little cheat sheet at the beginning of the presentation though for everybody to have. All right case five. We have an upgrade of a leadless system. So this one is an upgrade from a single chamber to a dual. This patient has 6 sinus syndrome with that sinus bradycardia. They have persistent AFib. They have an existing RV leadless system despite the AFib ablation that they've had and Sotalol medication that they're on. They keep having episodes of the AFib and they're also going into sinus brady which is leading to issues with the patient. So they are going to upgrade their system to also pace the right atrium. So again here just normal phrasing of presenting to the lab, getting all the consent. We have anesthesiology involved again. So down here is where they're going to prep that the AR device. So that's our right atrium device. Again as they go it get it into place and advance it under fluoroscopic guidance they find a good position. Again they're going to be doing different pacing and threshold measurements to find the most acceptable position and once they find that they release the device into place. So again this one's pretty straightforward. Again the RV was an existing and what we added was the R8 device. So what we end up here is a 0796T. So this is an upgrade to that dual with an existing RV component already there. So this is the component of a dual but just the right atrium component itself. And then again we had sick sinus syndrome. We had our AFib and then we also have our Z code for our clinical trial. All right single chamber leadless. So I basically had a case example for all the different ones today. So this one is a single chamber system but only to the atrium. So they don't have an existing the RV leadless system like we just had in our last case. So this one has an extensive history of device implants and extractions in the setting of symptomatic bradycardia with sick sinus syndrome and infections presented for atrial lead extraction due to right-sided chest discomfort. So basically the patient has that long history of having device implants. They've had infections in the past. Current device is causing the patient to have chest discomfort. So what the provider is opting to do is remove the system in place, the permanent system, and they're going to put the patient on a leadless system. So again here general anesthesia is involved. Temporary wire was in place, placed in the RV. A balloon was positioned in the SVC for possible SVC tear. So I get this a lot too. Can you bill for that when that's done? No. They're placing it as a precaution. So just in case there's a tear, they have a balloon in place to intervene if they need to. But you can't bill for it because it's basically as they're putting it there as a preventative. So no billing for that. Can't bill for your temporary wire either. Any kind of temporary system that's put in, it bundles with everything and Medicare's NCCI will not allow you to override that at it for anything. It says no modifier allowed. So we can't bill for that temporary wire that's put in and we can't bill for the balloon as it's done for preventative measures. So right-sided chest pocket was exposed. The generator was removed from the pocket because remember they have a permanent system in place so we're taking that out. And then it looks like they then advanced to the distal tip of the right atrium and the helix was retracted. However, the lead was not able to be removed with resistance at the tip of the lead. So this is them trying to remove the existing right atrial lead. Then they go ahead and use a laser sheath and then they advance that to the distal tip of the right atrium lead. And after using that laser, they were able to safely remove that lead. So now we have removal of our pacemaker generator and we have removal of the right atrial lead. It does state TE was utilized to confirm no effusion, but that would be documented in a separate report so we're not going to address any coding for that. So now our right femoral vein access site was upgraded to the aviar sheath. So that's our leadless sheath. Now they're advancing that into the right atrial appendage region and they're viewing that on fluoroscopy. Fluoroscopy is always bundled with our device procedures as well. The device was then advanced into the right atrium. After it was noted to be in satisfactory position and they got good parameters done, they go ahead and deploy that device into the right atrium and then wrap up our case here. So here for this case, we have a 0823T. This is a new right atrial leadless system. Again, our Q0 because those are in a clinical trial. We have our removal of our pacemaker generator so our 033233 and then we also have 033234 for the removal of the existing right atrial lead. The T code is for that the device pain that the patient's having in the chest due to the device and then we have our 6 sinus syndrome and our Z code. You can already tell I'm looking at the questions box. There are tons of good detailed questions in here so we'll try to get through the cases here so I can take some at the end. All right, case number seven. This is our last device case. This is an upgrade of a single chamber pacemaker to a CRT-P device. So that's that cardiac resynchronization therapy and then the P is for pacemaker. There is a CRT-D also that would be your defibrillator system so just so you know the difference between the two. So here in our procedures performed or what we call our wish list it's an upgrade of a single chamber pacemaker to that CRT-P device also an upper extremity venogram. This patient does have mixed cardiomyopathy. You can see they have ischemic and non-ischemic. They also have an EF of 35 to 40 percent with that documented chronic systolic heart failure. They have complete AV block and induced left bundle branch block. It does say they have subclavian vein occlusion. So this was the case I was talking about earlier when we were going through the venogram slide. They do a venogram. So here okay so this this top here is just you know consent and all that anesthesia is involved for moderate sedation but right here prior to starting the procedure the device pocket was examined because again they have a single chamber system already in place using fluoroscopy to document the location of where the chronic leads in an effort to avoid any damage to those chronic leads. They do an upper extremity venogram that was performed and it does show the vein was subtotally occluded with collaterals. Now again looking at this what do I have up here documented in my indications to show that this venogram was done for something separate than just placing the leads itself? I don't have that documented. Yeah the venogram showed that they had occlusion there but is the patient symptomatic? Why else would you have done the venogram if it's not just done to help place the leads? So again for just because I have it documented like this you're going to see at the end when we get to the final coding I don't code the venogram because I don't have enough to support the medical necessity. Even though I have findings I don't have anything to show why you did that venogram other than placing the leads to begin with. So again documentation is key. So again after they get that sedation done they do an incision along that existing scar where the generator is located. They go ahead and get that open and they excise and remove that device. They then the existing device and chronic leads were then freed from the removed pocket and then again they're talking about that subtotal occlusion. They couldn't get passed through. They go through another access. So again it shows the occlusion and all that. I have findings I just don't have the initial reasoning for them doing that venogram. So down here you can see they get into the coronary sinus. They do another venogram to help to find that target vein. So again that's definitely done to help place that lead. They do get the LV lead placed it says and then down here they get it secured. Once leads positions were rechecked on fluoroscopy the newly placed and chronic leads were cleaned and connected to the appropriate generator header ports on the new generator and the old generator was discarded. So when we're wrapping up our case they go ahead and you know attach everything and get it into the pocket and secure everything and then you can see in our little summary the X-Planet pacemaker generator model is this. This is our new pacemaker generator. We had an existing chronic RV lead which was placed in 2015 and they added that LV lead. So what we end up here is with an RV lead and so we have a by V system. We have no right atrial lead though there was a patient doesn't need it. So and then again oh this one did have moderate sedation so I might have looked at the start of the case too soon. So this one has good documentation for that moderate sedation you have you know the phrasing you need the independent trained observer your time all that good stuff here and then you can see what the final settings where the VVI are. So this is language in your CPT book and in the guidance section of where your devices are. Number of leads and chambers so a single lead system is where it's pacing and sensing only in one chamber of the heart. Your dual is when it's pacing in two chambers of the heart. Multi is three or more chambers. So keep all that in mind. This is actual language in your CPT book. So our final coding here because I know this was going to cause controversy. We only have an RV and an LV lead which are two chambers. So we had a generator taken out a new one put in. We did not have a right sided lead procedure performed with this. We only had a left ventricle lead implanted. So we're going to code for a generator change. Patient left with two chambers pacing so 3 3 2 2 8 3 3 2 2 5 for your LV lead addition and then moderate sedation and then all of these diagnoses that were documented well within the indication. So again patient has two chambers being paced in this case. There's no right atrial lead. All right we have three more cases and these next three are going to be pretty long because they're ablation cases that have additional ablations billable with them and they're all different. So we're going to this first one is a box ablation. So remember that anatomy picture at the beginning when I showed you the box in the center of the pulmonary veins. That's going to make sense as we talk through this case. So this patient has symptomatic persistent AFib and atrial flutter that is not you know they're on anti-arrhythmic drug therapy but they're presenting now for the ablations for both arrhythmias. So that means these are both clinically indicated in the patient's chart. This is the wish list. You can see some of this stuff is not billable anymore. It's bundled so sometimes you know providers might still be using a template that is maybe needing to be updated. We know 3D mapping is not separately billable with our PVI. Neither is our intracardiac echo and then we'll verify if we can do the medication you know whether that's done diagnostically or not. Anesthesiology is involved on this case. Remember with a pulmonary vein isolation it's very rare that I see moderate sedation done on these. Usually there's an anesthesiologist involved and they're doing general anesthesia. So there have been a handful of times I have seen moderate done on these but it's not common. All right this part of the report it's just the informed consent and all that draping the patient getting all the different sheets into place. Remember with an ablation case they do place multiple catheters. So that's all this whole page is about. All right now we're getting our intracardiac echo probe was inserted. Remember your intracardiac echo is now bundled and not separately billable with our pulmonary vein isolations. Transseptal is also not separately billable anymore. That bundled also a couple years ago. The reason why is because transseptal and intracardiac echo are always done on a pulmonary vein isolation. So they just bundled it because of probably that reason. They have to be done on every single case. So again they're just getting into place. I always when I'm looking at an ablation case I always like to see them document at the start of the case if the patient's in an arrhythmia or not. I just think it's helpful to paint the picture at that point. So this patient and you know sometimes they may arrive in sinus rhythm and stay in sinus rhythm the whole case but that and that's fine you can still bill your case. The clinical arrhythmia has been present and being treated by the provider you know otherwise but so they don't have to be put in the arrhythmia if that clinical arrhythmia is documented and treated by that provider. So again keep that in mind too. This patient does arrive in sinus rhythm but they develop typical atrial flutter which then converted back to sinus rhythm during the ablation. So remember our clinical arrhythmias for this case are persistent AFib and flutter. They were able to hit the patient in the typical flutter during the study. All right so down here we get our 3D mapping in place. Again that's bundled as well. Again they got a temperature probe in the esophagus which is standard for a PVI ablation and then your intracardiac echo. After they do their 3D map completing they talk about the radio frequency ablation was performed at 40 watt power down here and then down here they talk about the pulmonary vein isolation was then performed for all four pulmonary veins. And the next slide here they're talking about the esophagus temperature because sometimes the temperature while they're ablating the pulmonary veins can rise so they do keep a close eye on the esophagus while they're ablating the pulmonary veins. So that's all that this section is talking about. Down here they talk about this is where they've completed the pulmonary vein isolation and confirmed that exit block was demonstrated. Here though they state the patient remained in AFib. Therefore a left atrial roof line was performed by extending lesion sets from the posterior aspect of the isolated left upper pulmonary vein to the right upper pulmonary vein using that 40 watt power again. And then next they do an inferior line by extending the lesions of the isolated left inferior pulmonary vein to the right inferior pulmonary vein. Thereafter all electrograms on the posterior wall in the area of the posterior wall box. So remember we talked about that that box. So here they did a roof line and then they did the inferior line so they just did the top and the middle but that still forms a box. So now we have a posterior wall box. Now mind you the patient remained in AFib therefore that's why they did the posterior wall box. But after they did the roof line they don't state anything was still present so the provider knew they were going to be doing both lines in a sense which is why they called it the posterior wall ablation anyway. So this is only going to be considered one additional ablation. When the provider knows they're going to do that box ablation they could do you know a roof line and then the floor line which is going to be a bigger section. But if they know they're going to ablate both of those lines because you know the patient's having activity within that posterior wall itself that's only considered one additional. Now we do have another case coming up where they do end up doing two lines but the provider spells out why they do each individual line. So they don't their report shows in that case that the intent was not just to do a box ablation they're actually addressing the different abnormal signals that they're seeing within. So we'll cover that one here in a few minutes but for this case the intent was to do that posterior wall box with that roof line and that inferior line so that's only going to give us one additional 93657. All right and then down here we have adenosine that's done so this is our medication testing and they're doing doing it to assess for inducible atrial tachycardia or diagnosed presence or absence of dormant conduction across the enteral isolation lines. So here you can see they're doing it to try to induce another atrial tachycardia so this is showing it's being done for diagnostic purposes not just to confirm that their pulmonary vein isolation was successful and then you can see after they do that and confirm that there is a block across all veins they do another infusion of the adenosine along the posterior wall and it shows everything remained isolated and there was no further inducible atrial tachycardia. And then remember at the start of the case the provider does talk about they induce that typical flutter which in our indications it showed the provider was intending to address their atrial fib and the atrial flutter clinically. So here because they did induce that typical flutter at the start of the case they're going to now perform that CTI line for that typical flutter so that's what this whole section talks about here. And then at the end, they do wrap up and do an EP study. And this is all the findings of the EP study. And then the case is wrapped up from there. So, sometimes with the ablation case, they might start and do the EP study at the start of the case. And then sometimes they do it at the end. It doesn't matter where it's done at. So, again, and with the revision to the guidelines that are starting in 2025, again, if there's just any component of that EP study they can't perform, or maybe it's not clinically indicated. Because sometimes it's not, they don't need to do it. They just need to document why. That's the only difference with next year. All right, final coding here. We have 93656 for our primary pulmonary vein isolation. Our 93657 for our posterior wall box, which included our roof line and our inferior line. 93655 for our CTI ablation for the typical flutter. And then we did report our medication testing because they were doing it for diagnostic purposes. All right, two more cases. Case number nine is a pulmonary vein isolation with additional ablations. Again, this patient has a history of paroxysmal atrial flutter. Her episodes have become more frequent. They're occurring several times a week. And lasting for up to three hours. They're unable to tolerate rate controlling medications. Therefore, they're going to try doing this catheter ablation to hopefully get some success. Again, anesthesiology was involved. This one had an arterial line that was placed into the left radial artery for continuous blood pressure monitoring during the case. So this art line was placed to, it's not done as a separate procedure designation. So this one's going to NCCI edit. So we will not separately build this art line because it was done to monitor the patient during the case while it was being performed. Again, esophageal temperature probe was placed down. Again, it's pretty standard for a pulmonary vein isolation. Like I said, they monitor the esophagus to make sure it doesn't get unstable while they're ablating the pulmonary veins. Here, we're getting our sheaths into place. Fluoroscopic guidance, getting all the catheters going. Here's our intracardiac echo was placed. Here's our transeptal. So again, we've talked about the last case when they're doing a pulmonary vein isolation, they're always going to do transeptal puncture with that intracardiac echo. Those are bundled, of course. So that's all they're doing down here is just getting all their catheters and stuff into place. Here's our 3D mapping. Again, that's now bundled as well. The patient at the start of this case was in sinus rhythm. And remember, we have that clinical proximal atrial fibrillation that we're treating. It does show that there was a scar around the pulmonary veins. Otherwise, the rest of the heart was pretty healthy. They're going to get that BioSense Webster ablation catheter into place and it shows that they're using the map to the esophagus at the start of the case. The esophagus seemed to be right down the middle of the heart. Burst pacing in the high right atrium was done at the start of the case. It was able to induce that atrial fib. Remember, they arrived in sinus rhythm. And then repeat pacing was able to wake up some type of typical atrial flutter, which again, self-terminated within a minute. And then ablation lines were made around the left superior and left inferior pulmonary veins at that 30 watts. Then they go and do partial isolation of the left atrial appendage that was performed by ablating through the ridge, the roof, and the anterior side. Then they do ablation lines made around the right superior and right inferior pulmonary veins. So this is now showing that both sides of the veins are being isolated. And then from there, they induced an atypical atrial flutter, which then degenerated back into atrial fib. A roof line was then made, joining the left superior pulmonary vein with the right superior pulmonary vein. And then this terminated the atrial fib back into sinus rhythm. Because they did induce that typical right-sided flutter, they're going to go now and do that CTI ablation. Oops, sorry. So they go in and do that. Let's see. So down here, they're doing additional burst pacing that would induce AFib again, but it would self-terminate within 30 seconds to a minute. It was felt that there was still further triggers of AFib remaining. So the ablation catheter was placed into the distal coronary sinus and ablation was made from the distal coronary sinus at 25 watts. Let's see. Then the ablation catheter was placed back into the left atrium and a floor line was made at 30 watts over the coronary sinus. Burst pacing in the high right atrium still was able to induce AFib. That would self-terminate within 30 seconds again to a minute. While an AFib mapping with the diagnostic catheter showed fractionated atrial electrograms on the septum. So those are those cafe lesions. Ablation was made on the septum at 30 watts. So this patient had tons of ablations in the case done, as you can see. Even after doing that ablation, doing more burst pacing, they were able to induce AFib again. And then it says this time it would often organize into a focal atrial tachycardia before terminating. And this seemed to be earliest in the left atrial appendage. So now they're gonna look at that part. So ablation was made at the base of the left atrial appendage at 30 watts. This slowed the signals in the appendage even further. Burst pacing again in the high right atrium now would not induce AFib, but did induce a slow atypical flutter. So again, ablation was made again through the ridge, the roof, the anterior side of the appendage, touching this up and it felt to affect the tachycardia. Decision was made to make an anterior wall line to block epicardial fibers from the appendage. So that anterior wall line was made. And then midway through the line of the ablation, the arrhythmia terminated back into sinus rhythm. So this patient had a lot going on. At the end of the case, they do place the patient on isopril, which is a medication they use for that medication testing. And you can see they don't really state anything other of the reason why they're doing it, but to confirm the adequacy of our ablation. They only talk about placing the patient on the isopril and then they confirm the pulmonary veins were confirmed electrically isolated. So this is a case I would not build a medication testing because they don't show they're doing it for any diagnostic purpose. And then from here, we finished our case. So you can see we had tons of ablations done. So final coding here, just following the MUE assignments is 93656 for our pulmonary vein. Oh, this should say paroxysmal. That was a mistype there, it says persistent. It should be the I480. And then we have our additional ablations. We had many done, but we have our roof line, the coronary sinus line, additional CTI ablation for that typical flutter. And then we also have the atypical flutter that was located in the left atrial appendage. This is a case where, you know, the documentation's pretty good. Obviously the patient was going in and out of multiple arrhythmias. You know, you could try to go above the MUE assignment on this case and appeal with the carrier. But again, that's just gonna depend on, you know, if you have any success with that or not. I would say if you don't have success with it, it might not be worth, you know, continuing the battle, you know, but if you do have success, then definitely report over the MUE assignment, but documentation would have to be good. And I think this case does meet that, you know, documentation requirement there. All right, case number 10, this is our last case. This one is a pulmonary vein isolation with additional ablations and a cardioversion. So remember we talked, I had a case, you know, today where the cardioversion was planned. So this patient has a history of non-ischemic dilation cardiomyopathy, left their LVEF is 35 to 40%. They have a history of VTAC as well as symptomatic persistent AFib and flutter. They do have a dual chamber ICD in place. Their AFib and AFlutter is symptomatic. So after discussion of treatment, they decided they're gonna present for AFib and flutter ablation as well as planned cardioversion. And these are all real life cases. So I do want you guys to know that with this case, I did verify there was an order and consent for the cardioversion. So that was in the patient's chart. So, you know, this case is gonna fully meet overriding that NCCI edit. So down here again, here's our wishlist. They do again state planned cardioversion at the start of the case in order to perform the pulmonary vein isolation. So again, planned is the key. This patient does have a defibrillator and they do reference that peri-procedural interrogation and programming, but remember with the pulmonary vein isolation, we cannot bill for it even if they perform it. So here again, we have ultrasound guidance, but we can't bill for that. This is just the sheaths that they're using, all the different catheters, transeptal puncture with their ice guidance. Again, the intracardiac echo again. A lot of times when they use the intracardiac echo, they use it to help facilitate that transeptal puncture, but a lot of times they're using that intracardiac echo to also make sure there's no pericardial fusion present. So the intracardiac echo has multiple purposes during an ablation case. With our pulmonary vein isolation though, it is bundled and you can't bill for it anymore. But if we did like an SVT ablation or a VTAC ablation and they do the intracardiac echo, you can bill that with those ablation cases. So here, this is just all the different reading stuff. So again, they're commenting with that intracardiac echo. There is a trivial pericardial fusion that is present at baseline, but this is unchanged throughout the procedure. So here again, consent was done. General anesthesia is being used. Pre-ablation baseline rhythm was atrial fib. The defibrillator was interrogated prior to the case and it was programmed for the duration of the case and the tachytherapies were programmed off for the duration of the case. So they did do actual paired procedural programming. Problem is, is we're doing this with the pulmonary vein isolation and there's an NCCI edit and it will not allow us to override it, unfortunately. So even though this is documented beautifully, I cannot report it still. All right, so catheters are positioned down in the coronary sinus. Here's getting the intracardiac echo in place, transeptal puncture. Prior to the ablation, we cardioverted the patient back into sinus rhythm as planned. So this is a group that we work with closely and the providers document very, very well. I sent a lot of feedback to them. Sometimes it's just educating the providers on the guidelines, what exactly needs to be documented. So this is a good example of having that relationship with your provider. You're just giving them the education that they need. Sometimes providers don't understand this. They don't know that the cardioversion is defined as an elective procedure by the AMA. So again, meaning it's planned. So if they plan at the start of an ablation case to cardiovert them, just have that order and consent on file and you can bill for it. So this, again, perfect case. They do it at the start of the case. They did terminate the atrial fib. Now they're gonna proceed on with their pulmonary vein isolation. So again, here, they're just getting through their transeptal, their 3D mapping and all that, getting their catheters into place. Now they're proceeding with isolating the left pulmonary veins first. So that's where they're starting. We then isolated the left superior pulmonary vein and the left inferior pulmonary vein at 40 to 50 watts. And then post-ablation, exit block was confirmed. On the left side, we then evaluated the right side, which had considerable scar at baseline and no measurable voltage. Meaning, so it looks like the patient may have had a prior pulmonary vein isolation. So what that's saying is that the right-sided veins were not needed to be isolated again. That's okay. You don't reduce the service if only the left side's ablated again. CPT doesn't define it like that. It's just pulmonary vein isolation. So if you have one side of your pulmonary veins that are still effectively isolated and not medically needed, then there's no reason to re-ablate those. So we're still meeting our 93656, which is the left-sided veins only being ablated. All right, right-sided veins are still isolated. So that wasn't needed. While the atrial fib persisted though, we proceeded with creating a left atrial roof line ablation. A series of radiofrequency lesions were created along the anterior roof, connecting the areas of ablation from the left superior vein to the right superior vein. After the roof ablation line with catheter manipulation, the patient went into an atypical flutter. Removed the ablation catheter, re-advanced the catheter to the left atrium. They did mapping, and then they go ahead and do ablation in that area to terminate that atypical flutter. However, a new different atrial flutter then developed. You see, the provider documents well the different types of flutter. So you can even see the measurements. So this original typical flutter that documented at 400, this new one is now documented at 300. So that's showing it's a different mechanism. So that one then developed. They then mapped the second flutter, which was a CTI typical right-sided atrial flutter. So they pulled the transeptal sheath and ablation catheter back into the right atrium and form that CTI line. And then after the CTI typical flutter ablation, the patient then went into a new third atrial flutter due to extensive atrial scarring and the multiple atrial flutter scene, we then ended the case and did not proceed further with atrial flutter mapping and ablation. They cardioverted the patient again. However, after 30 seconds, the cardioversion, the patient went back into yet another atypical flutter. So we cardioverted the patient at the start of the case, and then we also cardioverted them at the end. You only bill that once regardless. So we had order and consent for the initial. If they wouldn't have done that initial and did it here at the end, I wouldn't bill for it because during the ablation and EP testing portion of the study, they actually put the patient in the flutter. So you can't put the patient in the arrhythmia and then shock them out of it and think you could bill for that. You have to get the patient back stable as they arrived. So the intent though here was to ablate the atrial fib at the start of the case, and they did do that with order and consent from the patient. So again, they just, with this case, they had to cardiovert them twice, but we're only billing for it once anyways. Post-procedure rhythm was atrial flutter at the end. Again, post-procedural ice imaging showed that there was no change in that trivial pericardial fusion and all catheters were removed. Post-ablation, the defibrillator was re-interrogated and reprogrammed and tachy therapies were programmed back on with final program. I mean, this documentation is beautiful. I just unfortunately can't override the NCCI edit and bill for it. So one of those cases that stinks, but it's like, I wanna give the provider all the credit for all that stuff they did, but I'm not allowed to. So this is just our little summary of what all the provider ended up doing. And then our final coding here, we have 93656 for our pulmonary vein isolation. We have the 57 additional for that roof line they did. And then again, they had multiple flutters. They did do the two flutter lines. That third one, they ended up not ablating. They ended up doing that additional cardioversion. Then we have our planned cardioversion at the start of the case. And then again, you're gonna add the 59 or the X modifiers just depending on your carrier. That was a lot of cases we covered today. So tomorrow we're gonna wrap up our bootcamp with Nicole and Linda, and they're gonna cover some non-face-to-face coding opportunities in our cardiovascular service lines. So be sure to check that out. There definitely could be some opportunities you find within that presentation that you could implement in your own practice. And then our disclaimer, CPT, and then Q&A. So let me, I have almost 50 questions in my Q&A box. You guys are awesome. Let me see what I can grab here in the next few minutes before we have to wrap up. All right, some of these are quite long, so I'll probably have to answer some of this offline. All right, here's a good one. Are Farah pulse ablations coded any differently? So no, from a physician reporting perspective, no. You're just gonna report your, it's just the ablation technique they're using. So sometimes they use radiofrequency technique. Sometimes they use the cryo, which is the extreme cold. Farah pulse is just another technique of ablation. Now, if you're reporting the facility side, they did create some new codes for that. But from a physician reporting perspective, which is what we're covering today, you're just gonna report the primary, your ablations that are supported by documentation. All right. If a PVI is performed during an SVT or VT ablation, does it change the coding, or do we still use 93653 or 5-4? So that's a great question. It's gonna depend on the arrhythmia. So I do see some cases where the patient is having issues with atypical atrial flutter in the pulmonary veins. And they're ablating the pulmonary veins for the flutter. Now, if the patient has that clinical history of the atrial fib, and the intent is to isolate the pulmonary veins because of the atrial fib, then that's, and even if only flutter's present in the case, you still would be 93656 because the clinical indications and history of the patient are for the atrial fib. But if you don't have that, and say it's for, you know, atrial flutter, then yeah, you're coding, you can only code a PVI ablation specific for atrial fib. So if you're doing a PVI for atrial flutter, your primary ablation at that point is gonna be 93653 because you don't have atrial fib documented. So these are specific to case examples. Do you need modifier 59 on one of the additional ablations when two are used? That's going to be carrier specific. So just make sure you know your payers policies and if they require the 59 when you have, it does have a MUE assignment of two. So again, some may want a 76 on it for a repeat. So again, just check your carrier preference on what modifiers they require, if any. I do know some don't require the modifiers at all. So again, it's just going to be carrier driven. What would you consider separate mechanisms? So a separate mechanism is defined by the AMA as a separate arrhythmia from the primary one that was ablated. So in that last case, it showed the patient had three different atrial flutters and the provider defined those flutters in great detail. So that kind of documentation is key to, you know, if your carrier denies because you reported, you know, some do, if you report an MUE of two, that is allowed, some carriers will still request the op report, you know, and it just could be something that they randomly do on occasion. So again, just having that detail spelled out in the op report by the provider is definitely key, you know, then defining the different arrhythmias that are present and why they're different from one another. Especially more so in a VTAC ablation because sometimes they do a VTAC ablation for PVCs and the patient could have multiple PVCs present during the case. So as long as they're defining those PVCs and, you know, the measurements and all that they're reading, that will show that they're a separate mechanism from the primary. All right. Somebody did ask if there was a webinar for the 2025 CPT updates. We actually did do that on Monday's boot camp session this week. So that presentation and recording should be up on our website, you know, hopefully next week. So if you did miss that presentation, just check out our MedAxium Academy site and you should be able to view the recording as soon as that's available. Somebody asked, does Medicare accept the Q0 modifier? Our auditors say not to use it with Medicare. As far as I know, Medicare, yeah, they need the Qs. If you're reporting that clinical trial, those clinical trials, that site, the link that I put on that site, that is a CMS link. So I've never heard somebody say that before. So yeah, if you're actively participating in the clinical trial, that Q0 modifier is necessary along with that additional Z diagnosis code. And then of course, your clinical trial number is needed. Somebody says, how do we record our attendance? That should be automatically done since you have registered and logged into the session. And then our team will upload your CEU certificate, like we said, within one to two business days. We do have a very high number of registered attendees for all of our sessions this week. So you know, it could be a possibility where some of the CEUs may not get uploaded till early next week. So you know, just check your site. You know, within a week, if it's not up there, then shoot our Academy team an email. They'll verify your attendance and then they'll easily be able to get your certificate uploaded. All right, well, the rest of these questions are very detailed and great. So I will definitely compile questions into a Q&A document after the holidays, and we'll get that up on our website so everybody can have that as an additional resource. But we do hope that you join us tomorrow for our final session. We will be launching our webcast schedule for next year, early in the year. So just be on the lookout as we get those scheduled, and we'll post the registration details for those webinars up on our listserv, and then they get sent on in our newsletters and all that too. So I appreciate everybody's attention today with all 10 cases that we covered, and be on the lookout for next year for another advanced EP session. All right, have a great rest of your day.

Electrophysiology

EP case studies

Coding

MedAxiom

CEUs

AMA revisions

MUEs

Device implants

Leadless pacemaker

Venograms

Bundled services

Ablations

Provider documentation