Hey, everyone, if you're just joining us, we're going to give it a couple minutes to let everybody get dialed into the webcast for today. Good afternoon everybody. I'm going to give it about one more minute just to give time people or to give folks time to get dialed into the webcast. All right, we'll go ahead and get started. Good afternoon, everyone, and thank you for joining us today. This is our first part of our EP series that we're going to give this year. My name is Jamie Quimby, and I am the Director of Coding with our Revenue Cycle Solutions Department with MedAxSAM. Today, I'm going to cover the EP studies and ablations. If you're new to coding these services, this is going to give you a good foundation of the guidelines and reporting options available. If you're a seasoned coder for these services, this is going to be a good refresher for you. In the second series that I'm actually scheduled to give three weeks from today, on that one, I'm going to cover EP device procedures, and that's going to include all our device implants, our pacemakers, defibrillators, our subcutaneous implants. Then in the third series that we're scheduled to do, that's going to be later in the summer, and that one I'm going to cover the EP device monitoring services. If there's any interest at the end of the presentation today, there's a survey. I'm thinking of possibly giving an advanced EP session during our bootcamp in December. If that's something that you would be interested in hearing or any topics that you are interested in hearing, if you fill out that survey, we get a copy of that and that's super helpful to us when we're planning future webcast. There could be a possible fourth series if there's enough interest in doing that more advanced session. Just a little housekeeping to cover real quick. To access our slides for today for the presentation, you can click on the chat box and a copy of the PDF file is going to be uploaded there for you to download. If you do have any questions related to our topic today, please type those in the questions box, and then we will review those. We do compile all of our questions post webcast, and we will put that document on our MedAxium Academy website. Please remember though to keep your questions on topic. If you have questions that you have for the device related services, just save those for three weeks when I give that presentation. We have a MedAxium Academy that everybody's probably familiar with by now, and all of our presentations live there now, which made it much easier to access those recordings. But you also have a personal account now with that, and your CEUs are uploaded to that account. Give our team about one to two business days post webcast. This webinar will be offered on demand. I'm giving it live to you today, but if you have colleagues that maybe couldn't register or attend today and they want to listen to it later, you will have the option to log in and listen to the on-demand, but you will have to take a quiz. If you're listening to it live today, you will not have to take the quiz. This is just a screenshot of how to access your CEUs and claim it, if you're not familiar with this. Once you log into your Academy account, you'll find in your history under the My Academy, the session that you want to open, you just click on it, and then it's going to open up a little box down here. You click on the Claim CEU, and then there will be a PDF that you can download. You can put it on your desktop or you can open up that PDF and print it immediately, whatever your preference is. But that is how you will claim your CEU certificate after the webcast. Now we're just going to cover some of the anatomy and physiology that's related to our EP studies and ablations. As a coder, I code these services every day. It's just so important to understand the anatomy of the area that you're coding. It really helps make it easier to comprehend, I guess, in a sense, what the provider is doing. If you're in an office where you can actually communicate more with your physicians, or I know a lot of us were remote now. Back in the day though, when I was with the practice and was able to see providers face-to-face, that's really how I learned a lot of what I know with cardiovascular, just talking to them. I would have providers that were open to letting me ask them questions, and they were totally fine with explaining stuff to me to make it make sense. If you have that opportunity, I highly encourage you to talk to your providers. A lot of what I'm going to talk about with you today is stuff that I have actually heard from EP physicians. I'll share some of that knowledge of what I've been told. A lot of the different techniques with the ablations now, I'm sure a lot of people have heard of the new, the PFA, I think is what it's called, but we'll talk about that in more detail. But a lot of physicians will fill you in and talk about what the newest thing is that they're doing. Again, just having that understanding of the area you're coding, the conditions that provider's treating, all that stuff can help you as a coder, especially since a lot of us don't have that clinical background. Just to start though with the electrical system of the heart. Again, this is going to be related to our EP studies in the ablation. 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 that contraction of the various chambers of the heart. Groups of special cells in the right atrium called nodes, send out the heart's electrical signal, and then those signals then will travel along pathways, then into the ventriculars, and then those pathways are called bundle branches. You're going to hear pathways and stuff like that a lot during the presentation. A lot of that relates to the EP study portion. Again, you'll hear that verbiage throughout today's presentation. This is a chart that can help you better understand what you might see when you're looking at an EKG. Again, as coders, we are not trained clinically. This is not to teach you how to read an EKG. It just gives you a visual of how everything looks and what it could mean. It starts here by showing the SA node, which then would move into the AV node. You're going to see depolarization and repolarization a lot on the slide. The depolarization with corresponding contraction of the myocardial muscle moves as a wave through the heart. Then with the repolarization, that is the return of the ions to their previous resting state, which would then correspond with the relaxation of that myocardial muscle. Again, as coders, we are not trained to look at these, but can be helpful as far as when you're looking at an EKG strip and you see all these little lines, and then you see what the provider, the strip will have a reading, and then your provider is going to give what their actual interpretation of that is. Again, just a visual to help you with how that will look and comes together. Again, how some of the interpretations may be documented from the provider. Again, we're not clinically trained here, but just to help you get an understanding of what all of this could mean, these are just some tips as far as what some of the EKG interpretations could correlate to. All right. Let's go through some of the common arrhythmias that we would be addressing during an EP study or an ablation. I'm not going to cover every single one as we don't have enough time today. I think I have a little bit over 80 slides to talk with you today, and we have six case examples at the end that are all different. But I'm going to cover the more common arrhythmias that we do see. We're going to start first with just the baseline basics though. What is normal sinus rhythm? A normal sinus rhythm means it's a normal heartbeat, both with respect to the heart rate and that heart rhythm. A normal heart rate will fall between 60 and 100 beats per minute. Some patients could fall a little lower than 60 beats per minute. That doesn't necessarily mean they have bradycardia. That could be a normal beat for that patient. Really, it's up to the provider and their clinical judgment once they're treating a patient and whether or not they would eventually fall below that 60 beat per minute and maybe more into that bradycardia diagnosis. But for normal sinus rhythm, it's defined between that 60 to 100 beats per minute. Atrial flutter is a common SVT arrhythmia that we do see with our EP studies and ablations. In atrial flutter, the heart's upper chambers, the atria, beats too quickly. People with atrial flutter have a rhythm that's more organized and less chaotic than that of atrial fibs. We have two specific types of atrial flutter that we can code, and then of course, there's the unspecified option. The difference though between the typical and the atypical, just how they're defined clinically. The atrial flutter typical or type 1 or atypical, which is referred to as type 2, those are based on the anatomic location from which the arrhythmia is originating from. Also, atrial flutter can be described as clockwise or counterclockwise. If you're currently coding ablation studies, you probably see those types of verbiages in the reports now. Again, it depends on the direction of the circuit. With typical atrial flutter, this is localized to the right atrium and typically can be treated with that ablation procedure. Most likely, more commonly, it's done in that cavo-tricuspus area of the heart. But again, if it's found in another area and the doctor documents it clearly, that's how you would code it. Atypical atrial flutter is localized to the left atrium. Most types of this flutter can also be treated with ablation, but it's more complex and more involved. The atypical flutter is going to be a little bit more complex than maybe a typical flutter ablation would be. Atrial fib is the most common arrhythmia that we see. It's an irregular and often rapid heart rate that can increase your risk of stroke, heart failure, and other heart-related complications. During AFib, 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 often includes heart palpitations, shortness of breath, weakness. If you are coding AFib and your provider lists all these other symptoms, make sure you're paying attention to your diagnosis guidelines because a lot of times, it will tell you not to report certain symptoms with that condition, especially if they're related. There are some people that actually have AFib that they're not aware of their condition. They have no symptoms. Sometimes a patient may be in AFib when they're being seen, and it's found during a physical exam with the provider, and the patient literally has no clue that they are actually in that arrhythmia. From a coding perspective, we have lots of reporting options, obviously. These were updated several years ago. Just to give you a background of how they're defined, again, it is up to your provider to clearly document the level of specificity. But just so you have a baseline of what each means, the proximal AFib is when you have symptoms that come and go. They usually last for a few minutes to hours. Sometimes the symptoms occur as long as a week, and episodes can happen repeatedly. The symptoms could go away on their own, or the patient may end up needing treatment. With persistent AFib, this often requires a pharmacological or electrical cardio version, and typically this arrhythmia would not stop within a week. With long-standing persistent AFib, it's persistent and continuous, and it lasts longer than one year. Then when you get to the chronic or permanent AFib, again, it would be up to your provider to document which one, but those are defined as a term used to describe the condition in people where the abnormal heart rhythm at that point just can't be restored. Most likely, they'll have AFib permanently, and often they require medications to control their heart rate to prevent that blood clot. Usually with chronic or permanent cardioversion, a lot of times it's not even attempted anymore, and if they do attempt it, a lot of times it's not successful. Again, I do want to stress that it's up to your providers to document those conditions in the highest specificity known. Again, if you see a trend where they're documenting a lot of unspecified and it's with an established patient, that would be one where I would be probably giving feedback to the provider, that we really should be coding these to the highest level, and more specified diagnosis would be appropriate if they can give you that. You may have unspecified if the patient's brand new to the provider, because a lot of times if it's a new patient, they're going to have to do workup and look at the patient's history and all that stuff to get that definitive diagnosis. The last condition we'll cover is our ventricular tachycardia. This is an abnormal electrical signal that's in the ventricles and it causes the heart to be faster than normal, and it's usually 100 or more beats per minute. It's out of sync with the upper chambers, which is the atrium. When that happens, your heart may not be able to pump enough blood to your body and lungs because the chambers are beating too fast or out of sync with each other and they don't have time to fill properly. Back with the ICD-10 fiscal year 2023 updates, we did get new codes for reporting ventricular tachycardia. You can see here on the slide, the options we have now. Again, it's up to the provider to give you that level of specificity documented, but ventricular tachycardia, it can vary in severity. It's usually a medical emergency when the patient is in that arrhythmia. This is because the condition can quickly turn into ventricular fibrillation, which is the most serious cardiac arrhythmia and can be life-threatening. Usually with ventricular tachycardia, they're obviously addressing it fairly quickly. Now we're going to jump into our diagnostic EP studies. Again, if you're new to coding these services, this is definitely going to give you a good understanding with what the studies are and what their purpose is. With an EP study, it's a test that shows how the electrical signals move in the pathways through your heart. When the pathways are normal, your heart beats regular. When the signals are abnormal, your heartbeat is irregular. During an EP study, the heart's electrical signals are recorded by the provider. The sensors in the catheters gather information about how that electrical signal is traveling through their heart. The goal is to make that irregular heartbeat happen again while the provider is doing the study. This way, the provider can then measure those electrical signals while the problem is happening. The measurements can then show what's causing the problem and help that provider find the spot on the heart that isn't working correctly. Medicines can be given through an IV to see if that fixes or helps see a regular heartbeat. Sometimes during an EP study, though, the provider may determine during that study that they want to go ahead and do an ablation. So again, we'll cover the ablations in some upcoming slides, but we'll go through those in detail. All right, so here's what you may see documented in a comprehensive EP study report. So in most cases, it's typical for them to hit at least three catheters, and usually they're going through the artery and veins. You know, it can vary, though. The most common is at least three catheters. They can vary from two to four, though. So once those catheters are in place, pacing and recording is performed in the high right atrium, the his bundle region, and then that right ventricle. An attempt at arrhythmia induction may be performed, and once this is completed and the sheets are removed, you should see in your report, you know, any results of the study along with recommendations and treatment. So these are the two coding options for our comprehensive EP study. Remember, with a comprehensive study, that would include your right atrium, your right ventricular, and your his bundle. And the difference between the coding is going to be, was there an attempt to induce that arrhythmia? The key here, though, is attempt. So sometimes you may be coding an EP study. They attempted an arrhythmia to induce an arrhythmia, but they could not. You would still code it as a comprehensive with the attempt made, even if the arrhythmia was not induced. They still tried to induce this, so that's the key there. If there was no attempt made, then you would just code the 93619. So what if you didn't have all three areas of a comprehensive study performed? Remember, you have to have the right ventricular, the his bundle, and the right ventricular, or the right atrium, his, and right ventricular. So sometimes they may just do a component study where they're only looking at one area of the heart. And an example I can give is, I see this done sometimes if they're evaluating the patient for ventricular tachycardia. So they only look at the ventricular portion when they're doing the study. They don't look at the atrium or the his. Say they induce the ventricular tachycardia. A lot of times from that single study, they'll go ahead and implant a defibrillator at that point if they've induced that arrhythmia. It just depends on the severity of it. But I do see that happen commonly with that. So then I would only be able to report the component codes for that ventricular EP study. So just to kind of give you an example. But again, so there are component codes in that unusual situation when that full comprehensive study is not performed. These services are multiple procedure reduction exempt. So you would not report modifier 51 as they're not required. So these are the component codes. So again, like I was saying, with the ventricular only study, if they're doing the pacing and recording, you would just do the 93603 and then your 93612 for that study. And then, of course, they induce that VTAC. And then from there, I actually coded a case like this last week where a patient ended up having a defibrillator replaced as soon as the component study was performed. All right. So now I'm going to give you some kind of clues with stuff and how you can tell in the reports if certain things were done. I get asked this a lot. How can you tell when recording and pacing were done? So the next couple slides, I'm going to kind of break that down for you. So one of the most, again, when you're placing an electrode catheter in a certain location and assessing the electrical activity that is defined as recording. The data that you could get or the findings that you may see in the report documented in the study would include the heart rate, the rhythm, the impulse travel speed, and any conduction blocks along the pathway. Again, if you're not fully sure, talk to your provider, have them show you in their reports where that would be supported. And that could just help you with coding future cases. You can help them try to addendum the report to make it more clear. But any of this wording correlates to that recording being supported. Pacing clues. So administering electrical impulses to specific areas is defined as pacing. Pacing allows the physician to test the various portions of the heart and how it reacts to the impulses. And then there's a number of other things that you can do. 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 that impulse? Again, so for pacing documentation clues, the physician will probably use the word pace. They're pretty good about it. But there may be times where it may not be clearly documented. So some other terms that you may see that is common in the documentation is drivetrains, the extra stimuli, burst pacing. You know, those types of language shows that the pacing, it was performed. These are some add-on component codes for the left. The 93621 is for left atrial pacing record. And typically you're going to see the provider place the catheter into the coronary sinus. That code is bumbled with all of our ablations now. So it used to be separately reportable until they did all the bundles a couple years ago. You can separately report the service with a comprehensive EP study with the induction attempt. If there's no induction attempt, then this code is not added on to the 93619. But again, if they just do an EP study, they try to induce an arrhythmia. And you can clearly see they did the left atrial pacing record. You can add this code to the 93620 now. Left ventricular pacing record is pretty straightforward. I most commonly see it done with a pulmonary vein ablation. A lot of times the provider could look at the left ventricular after when they're doing the EP study and testing. It'll be clearly documented though there's really nothing special they have to do versus just saying they did the left ventricular paste and record and then you know you would see findings in the report. Okay so mapping. The more common mapping system used is the 3D system. It is important to be familiar with the equipment that your provider is using. I do recommend sending a query to your provider if necessary to confirm. The thing with the 3D mapping is it's now bundled with all of our ablations. So there's a I have a slide to cover with you later in the presentation that's from CPT assistant so I'll wait till we get to that slide to kind of go into more depth between the services here. But there are two mapping services to available for reporting but just remember the 3D is now bundled into all the ablation services that we can report. So again the most common systems that we see documented are that 3D system. A lot of times the providers will list the system. Carto and Insider are the two more common ones. This right here is language that is in your CPT book. So it states do not report standard mapping in addition to 3D mapping. Again I just previously stated there was a CPT assistant article that was released in October of last year that relates to the mapping services with ablation. So I'm going to cover that in more detail because I actually printed exactly what CPT assistant says. So we'll go over that in more detail later in the presentation. All right program stimulation or what we typically call is medication testing. So the 93623 is an add-on code. It is separately reportable with all of these codes here on the slide. This is printed from the CPT book with what they allow it to be reported with. The key here and again I have another slide from the NCC manual from Medicare. They have a section in the manual that is totally relevant to this. We'll cover that because I actually printed out what they have in the manual word-for-word. Long story short here is if they're doing medication testing after an ablation is performed and they're doing it to confirm the adequacy of that ablation and that is it. You cannot report the medication testing. Now a lot of times they'll do medication testing before they do the ablation. So this is during the EP study phase of the of the procedure. They're doing it for diagnostic purposes. As long as it's done for diagnostic purposes you can report it even if it's done post ablation. So that's the key. The key really is what did your provider document and what was their intent. So that's the key. If they show they're doing it as a diagnostic service whether it's before or after the ablation you can report it. But if it's only done after the ablation and it's to confirm that ablation was successful then that's when you could not report the medication. That is only reportable once per session. So sometimes you may see them do the isoprol infusion during the EP study. Then they do the ablation and now they're doing a post isoprol post ablation isoprol infusion again. You know and they're even doing it for diagnostic purposes. It's still only reported once. All right our intracardiac echo is our last add-on code. So the intracardiac echo or what we typically call ice imaging. It uses the intravascular ultrasound imaging system in the cardiac chambers providing direct endocardial visualization. The ice is used during it's used to guide placement of mapping and stimulating catheters. It's also done it also helps the provider with precise anatomic location especially when they're putting in the ablation catheter tips. It's also common for them to do the ice imaging post ablation and a lot of times they're doing it to confirm that no thrombus got you know caused during the procedure. There's no pericardial fusion. So they do it multiple times typically during ablation procedure. More commonly with our pulmonary vein isolation. It is bundled with our pulmonary vein isolation now so you can't separately report it. But just to kind of give you an understanding it's used for multiple purposes during an ablation procedure. All right now we're going to get into our EP studies or EP ablation sorry. All right so a cardiac ablation is a procedure that can correct a patient's heart rhythm. Cardiac ablation works by scarring or destroying tissue in the heart that can trigger or sustain that abnormal heart rhythm. In some cases the cardiac ablation prevents that abnormal signal from entering the heart and thus it stops that arrhythmia. Cardiac ablation usually uses long flexible tubes that they call catheters. They're inserted through a vein or artery from the patient's groin and they're threaded to the heart and they deliver energy in the form of most commonly they use heat or extreme cold to modify the tissues in that area of the heart that where the abnormal rhythm is coming from. All right so we're gonna spend a little bit of time on this slide because I wanted to kind of cover common terms that we're seeing in our ablation procedures now. And we're gonna kind of go through how they're defined. So first is our radiofrequency ablation. This is an ablation technique that uses extreme heat. It's the more common one used. The cryo ablation is the exact opposite. It actually uses extreme cold. Epicardial ablation typically it uses either the heat or the cold energy. It's used to create tiny scars on the outside of the heart. The scars then block that faulty signal that can cause the heart to beat too fast. Now it doesn't matter which technique they're using during the ablation. With the ablation codes we have available you're focusing on the arrhythmia intent. So we have you know our SVT ablation, our VTAC ablation, and our pulmonary vein isolation for AFib. So it's really if they did an epicardial ablation for an SVT your primary ablation code is still going to be your 93653. But wanted to give everybody kind of a common verbiage that we can see in our reports. Because there is different ways they can do these ablations now. Cavotricuspid isthmus ablation are typically what we call a CTI line. This is definitely a common ablation done to treat typical atrial flutter. The CTI lines between the IVC and that tricuspid annulus. Cardio neuro ablation. So believe it or not this has actually been around since the 90s. I've been coding EP for 15 years and I don't have not seen a lot of these but more recently I have started seeing them more. So I don't know if it's just making a comeback but you may be seeing them too. I have seen some questions posted on the listserv about it and I've had members send me questions directly about it as well. So it's an ablation used to treat some SVTs but most commonly it's done to treat syncope or an AV block. Now again it's been around since the 90s. If it's done for syncope or an AV block we don't have anything we don't have a reporting option. You know the only option we have I guess I should be saying is unlisted. Because remember our 93653 ablation is for an SVT. Our 93654 is for VTAC and then our 93656 is the pulmonary vein for 8-fib. So if you're doing a cardio neuro ablation for syncope you know you don't have a code except for unlisted. Now I do have a case example that we're going to cover today where an attempt at a cardio neuro ablation was done. So we'll kind of talk through that case when we get there. But again if it's done for syncope anything other than an SVT, VT or 8-fib your only reporting option is going to be unlisted. The vena martial alcohol ablation. So this that is a chemical ablation completed by inserting a catheter and a small balloon directly into the vena martial. The balloon is then inflated occluding the vena martial to allow for injection of ethanol without spilling into other areas. It's commonly done to treat atrial fib. Reporting can vary depending on what all was done during the study. So typically when I see these done it's done along with the pulmonary vein isolation and then the provider will then do the vena martial ablation. You know and there could be other things done during the case. It really just depends. But if it's done during that pulmonary vein isolation and then they ablate the vena martial you're going to bill your 93656 and then you're going to bill that 93657 as your additional ablation for that vena martial. If they only ablate the vena martial since they're not touching the pulmonary veins and they're doing it for atrial fib your other option at that point is to bill the 93653. So again it just is going to vary on what what all is done during that case. All right another common term we see is the WACA. That is wide area circumferential ablation. This is used during a pulmonary vein isolation. It's just the type of technique and what they do is it's a radiofrequency ablation that performs circular lesions that encompass the ipsilateral pulmonary veins away from the ostea. Since the pulmonary veins are being isolated here your primary reporting would be the 93656 because they're doing that WACA technique to treat the pulmonary veins for that atrial fib. All right firm I actually have not seen a case with this yet but it's been around. It received FDA approval back in 2014 but that's a focal impulse and rotor modulation. But that's a focal impulse and rotor modulation. It's a mapping technology that allows doctors to precisely target the electrical sources of the atrial fib. So again if they're using this technology and they're ablating the pulmonary veins and it's for the atrial fib your again your primary reporting still going to be your 93656. All right and then last the most recent and new technique that we are seeing and you know if you do code this area a lot you're probably already seeing this. It's that pulse field ablation and I actually talked with an EP provider recently and he told me a lot of very positive things about this and I am starting to see it with a lot of the programs we work with. I am seeing this technique used more and more. It's used to ablate the pulmonary veins and it's used to treat the atrial fib. So again your primary reporting option if your pulmonary veins are isolated is still going to be your 93656. Now there is a clinical trial out there on this. So if your provider in the hospital system where the procedures are being performed if they're participating in the trial you're going to also append that q0 modifier and then that z00.6 as your secondary diagnosis. If they're not participating in the trial then it's fine you still they're ablating the pulmonary veins they're just using this pulse field ablation technique to achieve that. So you would still be reporting your 93656. Now on the facility side they are creating some new codes for this ablation catheter and I believe those are going to be effective April 1st. But from a professional physician reporting perspective we are still instructed to report the 93656 when they are ablating the pulmonary veins for the atrial fib with that pulse field ablation. You may see Ferripulse too. Ferripulse is from Boston Scientific. They actually received FDA approval this year. It was January 31st of this year where the FDA approved this device. So very new. I'm seeing a big increase with these being done though and it's what the EP provider I talked to told me is that it's giving a much better patient outcome and it's much safer for the patient. So you know he was very excited about it and you know like I said I'm seeing it a lot more with other programs we're working with. So I do think that this is going to become a favorite between EP physicians when they're ablating the pulmonary veins. All right this is a chart I made that you know you're free to download. Everybody's going to get a copy of the slides but it's just kind of a cheat sheet. It shows everything that's inherent and bundled and then what services could be separately reported if they are supported by that documentation. So again anything you see in red is a big no. Anything in green is okay. So I only included the comprehensive EP study with the induction attempt because without the induction attempt none of these add-on codes are applicable to that 93619. So the 93620 has a lot more reporting options and to be honest when it comes to EP studies I don't bill a lot of them. I don't see a lot of them. Most times they know they're going to be going in and doing the ablation. So when you're doing an ablation your EP studies are included in your ablation reporting. So you wouldn't separately be reporting anything because it's included. But when you get to your SVT ablation you know you can report your left ventricular pace and record if performed. Your 2D mapping if supported. 3D mapping remember is bundled with all of our ablations. In SVT you have your transeptal, your ice, and your medication testing and so forth. And we'll go through each ablation procedure individually but wanted to kind of share this slide with everybody in case you wanted to print a copy. I keep a copy printed on my desk and use it all the time. You know it's just a nice little cheat sheet where you don't have to open your book as much. All right so now we're going to go into each ablation reporting option. So our first one is our AV node ablation. This destroys the pathways from the atrium to the ventricular in an effort to create a complete heart block to treat a patient's abnormal rhythm. I see this done more commonly with a patient that has atrial fib. A lot of times they'll go in they'll do this AV node ablation, pit the patient in complete heart block which is now going to make them pacemaker dependent. And then sometimes they have the pacemaker pit in at that session. A lot of times though they'll have the pacemaker pit in first then they bring the patient back a couple weeks later and it's a planned procedure at that point. They know they're going to be doing this and they put the patient in the complete heart block and then they reprogram the patient's device. That's the more common scenario I see. But again when you're looking at an AV node ablation they may have some components of an EP study performed. A lot of times it's just a HIS study but those are included in the AV node ablation. You cannot separately report it. So again just keep in mind any portion of an EP study that is performed with any ablation procedure is not separately reportable. Also on an AV node ablation mapping is not allowed as an add-on service for the procedure. It's considered to be part of the service if it is performed. It's not always performed though but if it is it would not be separately billable. And in your CPT book if you look under both mapping codes they will list out what they are separately reportable with and the AV node has never been part of that reporting option there. So again the the big thing with the AV node ablation is you you want to see that the patient was pit in the complete heart block. That's part of how it's defined. It can include a temp pacemaker at the time of the session but temporary pacemaker for our cardiovascular services is if it's done in conjunction with another procedure. NCCI does not allow you to report it. It doesn't matter what you do what you document. It don't matter. It's bundles. There's no modifier allowed to override the edit. And again a lot of times they're going to put in that permanent device and it could be done before or it could be done as soon as they put the patient in complete heart block and now they're you know putting the pacemaker in. Our next ablation is our EP study with our SVT ablation. So this is the full how it's defined in the CPT book. So with with the SVT ablation rather than destroying the bridge between the atrium and the ventricle as we just talked about with the AV node the physician may destroy one of the pathways through which the electrical impulses are found. The SVT ablation is a more complex service than what the AV node ablation was but again this does include any part of an EP study if necessary. Sometimes it's not necessary for the provider to do a full comprehensive study. It doesn't matter if it's just a component code or you know a full you know blown EP study. It doesn't matter. It's all bundled so there's nothing you would change with the reporting. It would still as long as they're doing an SVT ablation you're going to bill your 93653 as your primary code and then any part of the component codes of an EP study would be bundled. Now what you can separately bill for if supported your 2D mapping. 3D mapping is bundled and again we're going to talk about mapping in an upcoming slide. Your medication testing if it's done for diagnostic testing purposes. Your intracardiac echo. Your transeptal puncture. Your left ventricle pacing record and from an SVT ablation perspective I don't see left ventricular pacing record done too often. I do see it done more often with the pulmonary vein isolation but not so much an SVT but if it is done you can report it and then the 93655 if there's an additional ablation for a discrete mechanism and we'll we'll kind of define those more too. All right a VT ablation is for ventricular tachycardia. A lot of times it can be done for PVCs as well so those are the two main diagnoses you're going to use to report a VT ablation with your 93654. This does include and always has included mapping. Mapping has never been separately billable with a VT ablation. Left ventricular pacing record is also not separately billable. It's included and then any component of an EP study whether it's just a component code or the full comprehensive that is also bundled. But what you can separately bill for is again your medication testing if it's done for those diagnostic purposes. I can tell you what I commonly oh this is a typo too that should be 93662. We'll have that fixed but oh the transeptal is too that should be 93462. Sorry we'll have that fixed so everybody can get an updated copy. But with the medication testing typically what I see like if they're doing it for PVCs and then post ablation they will do the medication testing. A lot of times what I end up seeing is the provider is trying to induce another PVC. So in that case since that was his primary mechanism that he was ablating that's where it's not going to be separately billable because you have to look for another mechanism. It has to be done for diagnostics. So if they say post ablation they're doing an isopropyl infusion and no further PVCs were induced well then you know that's one of those cases where I can't bill for it then because that was the primary intent of what you were ablating. You know what I mean? So it just really depends on the on the language. And then the intracardiac echo, transeptal catheter, and then if there's an additional ablation for a different mechanism after the primary. And then our last ablation which is the more complex and the more common one if you do code these services you probably code a lot of pulmonary vein isolations. This is specific to ablating the pulmonary veins and it's for the treatment of atrial fibrillation. There may be times where you're doing a pulmonary vein isolation and it's for atrial flutter. If you have a case like that you cannot bill the 93656 because it's not for atrial fib. You would have to then change your coding to the 93653 if you're doing a pulmonary vein isolation for flutter. So just keep that in mind. 93656 is specific to the pulmonary veins and it has to be for atrial fib. Now down here I want to point out and it was on the VTAC one too. You see CPT states do not report this code with all of these. One thing I want to point out 93286, 93287. This language was also on the VTAC slide. I skipped over it but the 93286 and the 87 are periprocedural device programming. So the guidelines do not if they have a device in place and the provider reprograms the device during the VTAC or the pulmonary vein isolation. Per CPT you cannot report your primary code with either one of these. So just keep that in mind when you're looking and I have a slide to cover too on the periprocedural services so and that information will be on there but just wanted to point that out. If they do programming of a device and it's for pulmonary vein isolation or your VTAC ablation, you can't build the programming. What you can build though with pulmonary vein isolation, your 2D mapping, if supported, your medication testing for diagnostic, your left ventricle pace and record, and then you have your additional ablations, whether it's a separate mechanism or additional to treat AFib remaining after that pulmonary vein isolation is complete. So these are our additional add-on ablation codes and we're going to cover these in the next couple slides in more detail. I do get a lot of questions on whether or not, you know, they, I'll have cases sent to me and, and, you know, they may be struggling to see if the additional ablations are reportable and it can get confusing and I do understand that. So with the 93655, you can separately report those with an SVT, a VTAC, or the AFib ablation. With the 93657, that is only added on to the 93656 as an additional. So, you know, just keep that in mind. These are given to MUEs, medically unlikely edits. So you can build this up to two times and there have been cases where maybe I'm doing a pulmonary vein isolation and the provider has to do multiple ablations after they've isolated the veins and I've built two of these and then they've induced other, you know, non-AFib, you know, arrhythmias, like maybe they induced a flutter and an atrial tachycardia and now I'm billing this two times as well. So I have had cases like that where I've built a primary ablation and I've built each of these twice. So it definitely can happen. But keep in mind, those do have the MUE of two. So this is introductory language for a separate mechanism that's actually printed in your CPT book. So basically what this means is once your provider has completed that primary ablation, any additional arrhythmias that are different from the primary ablation may be identified and then they could possibly be supported for reporting if they do the additional ablation. Sometimes they may induce or find another arrhythmia, but maybe it might not be significant so then they don't ablate it. So it's really just going to depend on what they've documented. Again, this is language that's printed in the CPT book. So just kind of kind of briefly summarize. It states the primary tachycardia is ablated. During post ablation testing, a different arrhythmia is identified. It would be considered a separate mechanism of the primary tachycardia. Therefore, it would be supported for reporting the 93655 if they do that additional ablation. They also did adverbiage on reporting the 93655 with a VTAC ablation. So again, it would be a separate mechanism. And usually with a VTAC ablation, whether it's for ventricular tachycardia or PVCs, most times that they're separate mechanism of the VTAC or the PVCs, the providers are very good at detailing out how each signal is defined and how they're reading it from the catheter placements and all that. So you can tell they're different mechanisms from one another. And then if they ended up ablating several of them, then you could still report the additionals. And then just again with the 936... you can add the 93655 on with a pulmonary vein isolation. It would just be for non-AFib arrhythmia. All right. These are some separate mechanism CPT assistant articles. We're going to cover several in the next few slides. This article came out in September of 2019. And the question was, would it be appropriate to report the 93657 for complex fractionated atrial electrograms? You're typically going to see either they'll spell out that or they'll say cafe lesions is another common term I see. So if you see cafes, then that is what they're talking about. So what CPT assistant said is, yes, it would be separately reportable. So what they're saying here is once the pulmonary veins are isolated, and during post-testing, the provider then identifies those cafe lesions, and then they decide to ablate, you can report the 93657 even if no further atrial fib is found. So that was a good clarification we got back in 2019. The next one we got back a year later in November of 2020. So this one came out and the question was asked, would it be appropriate to report the 93657 for a patient with persistent AFib if additional ablation lines are performed post-PVI with no further AFib and no cafe lesions are noted? CPT came back and said, yes, you could report the additional ablation. They state in their answer that if the patient has either proximal or persistent AFib, whether they are in AFib or sinus rhythm at the time of treatment, and the provider performs additional lines, then you can report the service. What they do say though, is there still should be medical necessity. So there may be times where the patient's not in AFib anymore, and maybe they did not documenting those cafe lesions, but they are documenting abnormal signals in that specific area. The provider, you know, they're saying the provider can perform that additional ablation. You're going to want to see some type of medical necessity. They can't just say they're doing a roof line as a preventative just because, you know what I mean? They have to say there has to be some type of abnormality there to justify doing it, but they don't have to be in the atrial fib, and they don't have to have those cafe lesions documented. Sometimes I'll just see them say linear lesions or patients having abnormal signals. They'll say something that's justifying the need for it. All right. This next CPT assistant, I get asked oftentimes, what if there are two primary arrhythmias that are scheduled to be treated? What if neither arrhythmia is present during the study? So I did a lot of digging through some of the old CPT assistant articles, and then I came across this one. It's from back in July of 2013, but what's asked in the question here is, please confirm what determines the primary ablation performed. Should the coding be based on the primary rhythm as determined by the physician, or is it based on the order which the abnormal rhythms were treated? So the answer here is the primary arrhythmia is the clinical arrhythmia that the patient is being treated for. So if that patient has that clinical history of the atrial fib, along with the clinical history of the atrial flutter, and the provider's intent is to ablate both of those arrhythmias, but neither arrhythmia is induced during the study, it doesn't mean you wouldn't report nothing. They still have the clinical arrhythmia the provider's been treating the patient. So you build these based on the hierarchy at that point. So the pulmonary vein isolation is the highest ablation reporting-wise. So there may be times where the patient comes to the cath lab, the plan is to ablate the pulmonary veins for the AFib history and to ablate for the flutter history. Sometimes they may do the CAVO tricuspid line first for the atrial flutter, then they may ablate the pulmonary veins for the atrial fib. You're still going to report your atrial fib ablation first because that's the highest ablation. And the intent was for the patient to have both of those arrhythmias addressed during the study. So that's what CPT assistant clarified here in this article. All right, this one, I feel I'm going to open a can of worms on this one. And this is that article I was talking about from on the mapping. And this is from CPT assistant back in October of last year. And what I feel it kind of contradicts what they say in the CPT book. So per CPT, you can code the 2D mapping with the SVT and the pulmonary vein ablations. But the 3D mapping bundles with both of those now. So 2D doesn't, 3D does. But what they state in the book under the mapping codes is do not report standard mapping 93609 in addition to 3D mapping 93613. That's actual printed language in your CPT book in the guidelines. So to me, this doesn't make a lot of sense because we know 3D is automatically included with the ablation codes. You can't separately bill for it now. It's part of the primary service. But they're saying you can report the 2D now in this article. The problem that really, it's going to come down to documentation first, because most providers are so used to using and documenting clearly the 3D mapping systems that a lot of times you can't even tell in the report if the 2D was done also. You just don't, you can't tell because they clearly define the 3D mapping systems, you know, whether it's the CARTO or the INCITE or whatever other system they use. But you won't, they won't clearly define where the 2D mapping is supported in the note. But if they do, what CPT assistant is saying here is you can report the 2D mapping even if 3D is also performed because of 3D bundles. To me, like I said, I feel like it contradicts what they say in their guidelines. Because like I said, in the printed book, where the ablation procedures start, you know, how you have all the guidelines and how they define certain things. It says that clearly there that the 2D mapping cannot be billed with the 3D mapping. So again, it's clear as mud, I know. My best recommendation is to check with your payers directly and see what kind of policies they may have. I have not seen a case where I could build the 2D mapping yet because again, like I said, a lot of times it's not clearly defined in the report. I can clearly see the 3D mappings done and we know 3D mapping is bundled. So again, that's my best advice. Just check with your payers, talk with your providers. Again, VTAC ablation, no mapping can be reported at all with that one. So this only is applicable to your SVT or your pulmonary vein isolations. All right, this was a wonderful photo I found several years ago. So I wanted to share it with all of our MedAxia members. It's just kind of gives you a picture of the anatomy of how the ablations look. This is super helpful when you're looking at a pulmonary vein isolation because right here is our pulmonary veins. A lot of times I get questions like, what if they do a roof line, which is here? And what if they do a floor line, which is here? Sometimes you may see the provider's document, they're doing a posterior wall box ablation. Well, what the posterior wall box ablation is, is this box right here that you see. So that would include a roof line and a floor line. So if they know they're doing a box ablation and they do both lines, you only build one 93657 once they've done the pulmonary vein isolation. There's no set clear guidance on this otherwise. So if the provider's document after they've completed their pulmonary vein isolation, they still see AFib. So now they're going to do a roof line. Then they do additional testing. They still see AFib. Now they're going to do a floor line. That's room to make argument to billing it twice at that point because their intent was not to start out doing a box ablation. You know, they're finding the AFib still present. So they continue to ablate. But if their intent is to do that box ablation, you only report the 93657 once. Because like I said, this is a perfect little box and that's what a box ablation is. It includes both the roof and the floor line. There's also an inferior line, which would be in the middle here. So there may be times you see all three lines done. But again, if their full intent is to do that box ablation, then you're only going to bill it once. Again, great photo here. It points out everything. Here's your CTI line that they typically do for the flutter. You know, your SVT is another common one. So really wanted to share this with everybody. I find it super helpful. Again, it just kind of paints that overall picture and helps you kind of understand a little bit better what the provider's doing. All right, now we're going to cover some NCCI edit reminders. Ultrasound guidance. Unfortunately, Medicare is very strict. And no matter how well your providers document ultrasound guidance, Medicare does not care. You can see in this policy, and this is in the NCCI manual word for word, they state ultrasound procedure codes if they're performed for guidance during one of the procedures described by CPT 33202 through 33249, which is all of our EP device procedures. And then 93600 through 93662, which is all of our EP studies through our ablation procedure. So it's the whole CPT range. So there is no way to override this. If they do the ultrasound guidance, you know, that's great, but you can't bill for it. Arterial lines, if these are placed during an EP procedure, they do have an NCCI edit. You can see how the 36620 is defined as a separate procedure designation. So the provider would have to be placing this arterial line for something not related to his procedure. And I can tell you, I've not seen that done ever. So anytime I see an arterial line done, it's usually done for monitoring during the procedure, which would make it related, which would then bundle it due to the NCCI edit. More times I see it done with a V-tach ablation, not so much with an SVT or the pulmonary vein, but a lot of times with a V-tach ablation, because of the complexity of that, they, a lot of times do place this arterial line, but again, it's related to the procedure. Can't separately bill for it. Cardioversions, this is always a hot topic. So cardioversions in the CPT are defined as elective procedures. So if the physician knows they're going to ablate the patient before they've, or they're going to cardiovert the patient before they do their ablation, to get the patient at a baseline rhythm as best as they can, patient does the consent for it, patient does the consent for it, you can bill for it. If there's no consent for it, the patient had no idea they were going to have it done. Even if they do it before the ablation starts, you can bill for it. That's the key here. This is an elective procedure. The patient has to know and consent to it. So that's the key. A lot of times they may cardiovert the patient after, you know, they've ablated them. At that point, you know, you can bill for it, you know, at that point it's bundled. There is an NCCI in it. So big key here is provider has a discussion with the patient along with them, you know, doing the ablation discussion. You know, they explain to the patient they want to cardiovert them prior, patient consents to it, provider ablates, does the cardioversion, then goes into their EP study with the ablation, then you're fine to bill it and you would append your modifier 59 to it. So again, just keep that in mind. 92960 is the more common one. The 92961 I've never billed for. It's an internal cardioversion and that's usually performed via open and that's not any kind of area that an EP provider would go into. This is the program, the medication testing I was talking about. So this is the actual language in the NCCI manual. So what I've pointed out here in red, it shall not be reported for injections of a drug with stimulation and pacing following that intracardiac catheter ablation procedure to confirm the adequacy of the ablation. So key term there. If it's done for testing purposes diagnostic wise, you can bill for it. And then this is the slide I was talking about earlier on the periprocedural programming. So remember I pointed out with CPT how they stated on your VTAC and your pulmonary vein isolation that it is not separately reportable. It is, however, with an AV node ablation or an SVT ablation. So if the patient has a pacemaker or defibrillator and you got one of these ablations happening and they program the device before and after the case, then you can bill for it. All right. Now we have some fun case examples. I think I have six to cover with you today. And I know we're already, I think we got 25 minutes left. So I'll try to get through them. And so we can answer a couple of questions live, but again, I'll take all the questions post-webinar and I will compile them all into a document and we'll put it on our website. So first case is a component EP study or it's a comprehensive, sorry. So our indication is SVT. So you can see here, I kind of highlighted certain words to kind of point out. So again, typically your reports, as you know, if you're coding procedures already, you get your consent and all that wonderful stuff. So here is where they're placing all the catheters. Like I said, with any type of EP study or ablation, they are placing multiple catheters. It can be anywhere from two to four, but it's more commonly at least three. Here you can see they're putting the intracardiac echo catheter in place. So that's all this is. It's just them getting all the catheters in place and into the certain areas of the heart. Here we have our left atrial pacing record, our right ventricular pacing record. And then here we have the catheter going to the HIS bundle for pacing and recording here. I always like to see in the report, like what, did the patient arrive to the cath lab in normal sinus rhythm? Did they arrive in whatever type of arrhythmia? If your intent is a pulmonary vein isolation for AFib, and maybe the patient doesn't have a clinical history of atrial flutter, but they arrived to the cath lab in atrial flutter. Well, now you have, you know, a separate mechanism from what your primary intent was. So I always just like to see that documented in the report and, you know, point it out. So again, 3D mapping is clearly defined here. Again, they're going just into the different areas of the heart, doing their mapping. Their ice imaging was used as a guide mapping system. Remember, that's common. And they're verifying there's no pericardial effusion through that ice imaging. And then here's our baseline EP study. They state drug stimulation was performed. Down here you can see the type of drug. Isoprel is a common one that they use. And you can see that they're inducing that. They are trying to induce that SVT, but they are not able to. So therefore they pretty much just wrap up the case. At the end, they verify again through that ice imaging that there was no significant pericardial effusion that occurred. And then they just wrapped up the case here. So this one we had, and I probably talked a little bit. They did go through the coronary sinus for that left atrial and pacem record with all the catheter placements they were placing. But we did have a full comprehensive EP study. So we got the 93620. You have your 93621 for that left atrial pacem record. They did have the 3D mapping, which is separately added on with the comprehensive EP study with the induction attempt. We had our intracardiac echo and we had our isoprel infusion. And then the clinical diagnosis they were trying to induce and treat was for that SVT. All right. This next one is not that commonly done, but it does happen occasionally. And I always get questions on how do I report this? So this is a medication challenge study. They don't do, that's all they do. They're looking at a patient that has symptomatic PVCs. So after they get the consent and all that, they get the patient on the cath lab bed, they get them hooked up to an EKG. They infuse medication here. They did one gram over 30 minutes. What they're trying to do with this medication is induce this arrhythmia. So they don't do, they don't get the catheters all put in a place and do any type of an EP study. Really they're just looking at the patient with an EKG hooked up to them and they're infusing that medication trying to induce that PVC, but they were unable to. So really all we had was medication testing for this type of case. And of course they say it's a negative challenge at the end. So what do you bill for? Well, the only option is 93799 unlisted because you can't build a 93623 by itself. It's an add on code. So in those types of cases where you just have a medication challenge being done, it's unlisted with your appropriate diagnosis. And of course, comparing price wise too, when you're trying to get your claim submitted, obviously it's recommended you would price it, compare it to the 93623. All right. Case number three is an AV node ablation. And patient has persistent AFib. And then here's, we have our consent. Anesthesia was involved. Patient has a pacemaker, which was programmed at the start of the case. Oops, sorry, clipped too fast. So now they're getting ultrasound guidance done, which is all great. We can't bill for it. So now they're getting their catheter tips and all that stuff get into place. Doing baseline measurements. The patient is in AFib. They then start doing the AV node ablation and the patient has then developed that complete AV block. And then at the end of the case, they're going to reprogram that patient's device to the appropriate settings. Now the patient's in complete heart block. So here we have 93650 for our AV node ablation, which did confirm the patient's now in AV block. You have your periprocedural programming for the start of the case, your periprocedural programming done at the end of the case. You can build this up to two times. It has an MUE of two also, and then our diagnoses would be our persistent AFib. They left the cath lab in the AV block, and then we have our pacemaker programming code. Those are pretty common. If the patient was in the 90-day global from the implant being done, since the AV notablations are planned, if it's within that 90-day global, most likely your carrier is going to require modifier 58 to be appended to the 93650 since it's a planned procedure. If it's unplanned, then you're going to be looking at your 78 probably. But keep in mind, when you're looking at these and it's within that pacemaker implant, if it's within that 90-day implant, then you're going to need a modifier because most carriers will deny it. All right. Case number 4 is an SVT ablation. It says proximal SVT in a patient that has that history of the sixth sinus syndrome. Here's our wonderful consent still. Now, here's our sheet. See, we have three being placed, which is, again, our common number. The catheters are then being placed in the high right atrium, the HIS bundle, that coronary sinus, and the right ventricular. This is the RA pacing and recording, the HIS bundle recording, the left atrial pacing recording from the coronary sinus, and the right ventricular pacing and recording were performed. This is our comprehensive diagnostic EP study with the attempt induction of an arrhythmia was performed baseline state and on and off the medication. Now, this is showing the medication testing is being done as part of the diagnostic portion. Then following testing ablation, they're just wrapping up, summarizing. Down here, we're going to get more of detail here. Patients EP study, their baseline rhythm was sinus rhythm. Then here's all the findings from them documenting that comprehensive EP study down here. Again, more findings here. Findings from them having the medication testing down here. Now, it shows that a narrow complex arrhythmia was induced with atrial burst pacing and that extra stimulus pacing. They were able to induce a tachycardia. It says they also wobble at onset of the tachycardia. We're seeing entrainment of the tachycardia with the ventricular produced. This is just, again, he's giving you findings of the testing as they're inducing that arrhythmia. Then they confirmed the diagnosis was the AVNRT, which is an atrial tachycardia. Now, because of that, they're going to go ahead and go in and ablate. Remember, now that we're looking at an ablation being done, our comprehensive EP study is going to bundle now. Ablation was performed here in that area of the posterior slow pathway along the tricuspid annulus. Intracardiac electrograms, 3D mapping, and then the fluoroscopy. Fluoroscopy is always bundled, never separately reportable with any of these studies. Radiofrequency lesions were delivered, so that's them talking about doing the ablation right here. They're using 40 watts at 60 degrees for 60 seconds. Then due to baseline, the patient went into marked sinus bradycardia. It states here a cardio-neuro ablation was attempted to modify the sinus node. There's not a lot of detail past that though. Then we have a transeptal needle was inserted. They do that transeptal puncture under the intracardiac echo guidance. That's standard when you see a transeptal puncture. Almost always, they're going to be doing the ice imaging with that transeptal puncture because it's helping them guide and puncture through that area of the heart. They're able to see it more clearly on that intracardiac echo. Then the guide wire was inserted through the needle of the left atrium and positioned within that left superior pulmonary vein, which then they go in and get pressures. Areas of complex fractionated electrograms, so that's those CAPA lesions I was talking about earlier. Those were tagged along the atrium of the pulmonary veins along the superior aspect of the lateral left atrium ridge. They do burst pasting at the tag sites, which resulted in brief non-sustained atrial tachycardia but no prolonged pause. Ablation lesions were delivered at the site using 40 watts power, but no significant change in the heart rate. Consolidation lesions were delivered around the area extended towards the left atrium roof. Additional lesions were delivered at the superior aspect of the lateral LA ridge. Then post-ablation, it shows the patient's in sinus rhythm. There were no inducible tachycardias despite atrial burst and extra stimuli pacing and then the ventricular burst pacing on and off that medication testing. They did the medication testing pre and post-ablation. Remember, you only bill it once regardless, and we do know they did it for diagnostic purposes at the start of the case. Our conclusions was they ablated that AVNRT, they did have that successful ablation, and then they had that attempt at the cardio-neuro ablation, but there really wasn't a lot documented there. Since we know they were ablating an SVT and then they had that additional ablation for the CAFE lesions, what the coding ended up being is 93653, because that's for our atrial tachycardia. The 93655 was for those CAFE lesions. We had our transeptal puncture. We obviously had our medication testing and our intracardiac echo. Our diagnosis is going to be the atrial tachycardia here. I didn't give any type of credit for that attempt at that cardio-neuro ablation because I would have to report unlisted number 1 because it wasn't done. It was done for bradycardia, which remember a lot of times when they're doing the cardio-neuro ablation, it's either done for syncope or some type of AV block. It said this patient went into bradycardia, they attempted it. There wasn't a lot of detail. Obviously, I had lots of detail in regards to the atrial tachycardia they were ablating. I did not give credit with an unlisted for the lack of attempt documented for the cardio-neuro ablation on this case. Case number 5 is our VTAC ablation. Then of course, our last case we'll cover, which is next, is going to be our pulmonary vein. I wanted to give a good variety of all the different ones that are available. With this one, their primary focus is PVC burden based off of the history. They got PVC-induced cardiomyopathy. Down here is our consent, all that wonderful stuff. Again, ultrasound guidance, can't bill for it. You can see here they're putting in the intracardiac catheter was advanced to your right atrium, right ventricular. Full ice report is below. The baseline rhythm was sinus rhythm that showed occasional PVCs with an RBI morphology. Then here again, normally when I see a case like this, they're giving very detailed readings of that arrhythmia that they're seeing. If there's multiple, each one's going to be clearly defined. It does help when you're looking at a VTAC ablation, if there are separate mechanisms of a VTAC or a PVC and they ablate them. Usually, most providers are very, very good at detailing this level of detail and how that arrhythmia is measuring out. Again, here's our intracardiac. This is all the findings they gave from the intracardiac echo, so that's going to be our 93662. Down here, you can see they're also doing medication infused down here too, which I did not highlight blue, but there it is. Then they proceed to do a transeptal puncture. Again, most commonly, we already know that they use the intracardiac echo, but more commonly they do the intracardiac echo in conjunction with that transeptal puncture. You can see our 3D mapping was done. Mapping has never been separately reportable with the VTAC ablation, whether it's 2D or 3D, so we know this will bundle. Then down here, they're getting testing done and they're seeing all the different signals from that arrhythmia. Again, here's more supporting documentation of the medication being infused. They're trying to see if any other arrhythmias were inducible. The language here with him, so let's go back up here. Down here is where they're talking about the ablation and all that stuff with the PVC. Then down here, they're doing the medication testing. They're looking to see if any other arrhythmias are inducible. If they stated here they were looking to see if any more PVCs were inducible, then that would automatically be a big no for me. But when they're defining it as arrhythmias looking for other, that there is supportive in showing that they're doing it diagnostically. Now, what ends up happening is they do end up inducing another mechanism of arrhythmia. You can see they induce typical atrial flutter. The flutter then degenerates into an atrial fib. Then they have to cardiovert the patient. At this point, cardioversion was not planned. They caused the induction of the atrial flutter to the atrial fib, and now they had to get the patient out of that to get them stable. Cardioversion here would definitely not be billable. They then stopped the medication. They saw no further clinical PVCs noted. Then they decide to go and do the typical flutter ablation because they did induce that up here from the medication testing. Then they go and do that cavotricuspid isthmus line, which is common for that typical atrial flutter, and then post-testing, and then post-ablation. Like I said, it's common they do this intracardiac echo just to verify that there was no significant pericardial effusion. That occurred during the procedure. Occasionally, it can happen. A lot of times if it happens, the EP docs will go ahead and place a pericardial drain if that does end up becoming an issue. Just keep in mind, they always do an intracardiac echo at the end. It's very common because they just want to make sure that there was no unknown issues that could have occurred. For this case, we had our PVC ablation with our 93654, our CTI line for that typical flutter that was induced, the 93655. We have our transeptal, our intracardiac echo, our medication testing. Big no on the cardio version, can't bill for it. You cause the AFib, and then these would be our two diagnoses for our two ablations. All right. Our last case is our pulmonary vein isolation using our pulsed field ablation technique. Like I said, I'm seeing a lot of these now. Then they did an additional AFib and a separate mechanism. This one, again, you can see our primary intent here is proximal AFib flutter, and then they have a persistent left superior vena cava, which is a congenital issue. AFib ablation using the pulsed field ablation technique. They also stated here in the wish list, they did a left atrial posterior wall, and then they also did the cavotricuspid isthmus line for that flutter. Down here is our wonderful consent and all that stuff. Then now we're getting our catheters into place. We got our right atrium, we have our ventricle and our his, and then they say the 3D mapping. Again, all this stuff is going to be bundled. Ablation of typical atrial flutter was performed using the radiofrequency ablation. They have their intracardiac echo. Now, remember when we're looking at a pulmonary vein isolation, your intracardiac echo, your transeptal cath is now bundled. You cannot separately bill for those now, so they're part of it. Because the transeptal and the intracardiac echo are always a component of the pulmonary vein isolation. When they did all the bundles a couple of years ago, they decided to bundle those in with that. Here you can see they're getting their catheter after they get through the transeptal and they're getting down in there. They get their ferripulse catheter into place. Now, with this particular, this case I borrowed from one of my EP docs that I work with. They are part of that clinical trial, but when that particular case is part of the trial, they actually put it on the operative note at the start of the case. This one did not have that, so I knew this patient was not in the trial. But I've had other cases for this group that I've coded for where they are part of that clinical trial, and it will clearly say it on the report, so I know that I need to get my Q0 modifier and then the Z006 diagnosis as my additional. But again, like I said, this one was not defined as being part of that clinical trial. Again, coding is still going to be, they're still ablating the pulmonary veins in this case, it's just the technique that they're using. Using the paripulse PFA catheter was used to get into the left atrium for the pulmonary vein isolation and posterior wall isolation. Again, they'll clearly define that further. Patient arrives in normal sinus rhythm and baseline EP study was unremarkable. Pacing was performed as part of the diagnostic portion of the procedure, 3D mapping of that right atrium, the SVC, the IVC, the HIS bundle, coronary sinus was performed to guide catheter placement as well as mapping and ablation. The intracardiac echo imaging demonstrated no evidence of an intraatrial thrombus. A full EP study was done, there was no evidence of the WPW, no evidence of accessory pathway conduction, just given findings of the EP study basically. Of note on that intracardiac imaging and the 3D mapping, that was where they found that evidence of that left SVC. Prior to the transeptal cath, they administer the heparin, which is standard. Then they do the transeptal cath was performed under that intracardiac echo guidance. They had to have great care to avoid the roof of the coronary sinus, given that is where the persistent SVC was located. 3D mapping was done, which is bundled. You can see what I'm saying here with the mapping. I can clearly see 3D mapping was done throughout this whole case. I cannot see where 2D mapping would have been done. After here, after they confirm, they get the pulmonary vein isolation was performed, and they're talking about each pulmonary vein using that ferrifols catheter down here. During ablation of the left pulmonary veins, here's your findings, and then now they go to the right side. Once they're done, confirmation of bilateral isolation was confirmed. Next, the patient's AFib persisted, therefore, they did a posterior wall isolation. Using the flower configuration, overlapping applications were made to the posterior wall to achieve that posterior wall isolation. Since we had AFib persisting post-pulmonary vein isolation, we now have an additional ablation with the posterior wall being done. Pulmonary veins were remapped, and this is just confirming the posterior wall was completely isolated along with the pulmonary veins still being completely isolated down here. Following isolation of the pulmonary veins, they are mapping the persistent left superior vena cava. This resulted in a triggered atrial fib from this site, therefore, it was targeted for ablation. The ferrifols catheter was advanced, and then they ablated the superior vena cava due to that AFib being triggered. There was marked vagal response and this following this, no further AFib recurred following cardioversion. So here's another one. I don't have a consent for the cardioversion. It's done after my ablation's performed, so therefore, it would also not be separately reported. Now here, this patient has a clinical history of typical atrial flutter, so the provider clearly documents that they're going to pursue ablation. They clearly know we did not decide to induce the atrial flutter during the study given the history of the atrial flutter on an EKG and monitoring. A typical atrial flutter ablation was performed using the radiofrequency ablation. This confirmed the CTI block was achieved, so the patient had the clinical history of the arrhythmia. So the intent at the start was to ablate the pulmonary veins and also do that AFlutter ablation with the CTI line. So even though they didn't induce the flutter, they have that clinical history, so you would be separately reporting this still. And then they wrap up the case at this end. Again, at the end, they confirm there's no significant pericardial fusion on that intracardiac echo. So we have a 93656, our pulmonary vein isolation. We have a 93657 twice. We had our posterior wall for the persistent AFib or the AFib that persisted. And then they also induced that second AFib in the SVC, so they ablated there. Then we have our clinical history of our flutter, so we're going to build the 93655. No cardioversion on this one because it was not planned. All right, helpful abbreviations. I definitely find these extremely helpful, you know, just common ones we see here, but this slide here is very helpful. There's sometimes when I'm looking at a component study and I'm just like, what do these measurements correlate to? You know, sometimes they don't really spell it out so clearly for us. So again, just something you can refer back to and use, you know, if you're coding these services day-to-day but definitely helpful. These two areas are very helpful. I use them often. And then this is just our disclaimer stating this is for informational purposes only and does not constitute legal reimbursement, coding, business, or other advice. You should always check with your local Medicare carrier and consult with your practice's legal counsel for coding and reimbursement advice. And then everything we went over today is CPT copyrighted from 2024 a year. And then that brings us to our questions, which I know we're right at time. So let me just see if I can find a couple that are pretty straightforward. Usually I get a lot of detailed questions. So like I said, I will put all of these in a Q&A document and we will add these to our MedAxema Academy account. All right. Is the mapping CPT 93613 allowed with the AV node ablation? No, it is not. Mapping is not allowed with AV node. No part of a component EP study are allowed. Like I said earlier, with an AV node ablation, it is common for them to record the HIS, but it is part of the study. It would not be separately billable. All right. Can you charge for the pulmonary venogram during an AFib ablation? I have not seen where it's supported for that. I guess it would be what is the intent and is it done for diagnostic purposes? But like I said, I have not seen one where a provider's doing a pulmonary venogram during a pulmonary vein isolation. Somebody says, please confirm what CPT code for venom marshal is. I thought the code was 93583. 93583 is something totally separate and it would have to do with the septum. So when we're talking about a venom marshal ablation for treating an arrhythmia, like I said earlier, it's most commonly treated for atrial fib, then it's going to depend on how much they got done. Like I said, if they do the pulmonary vein isolation and then do the venom marshal, and they're doing the venom marshal for that AFib arrhythmia, then you're just going to do the add-on code. You'll do your 93656 with your add-on ablation code. So the 93583 is definitely not related to a venom marshal ablation to treat AFib. All right. Is it required to document a complete heart block for 93650? Yes, it is. That is the whole purpose of an AV node ablation is to put that patient in complete heart block, and they do it so they can try to better control the patient's arrhythmia. And like I said earlier, most times when they're doing an AV node ablation, it's to treat atrial fib. A lot of times they've probably already tried to do a cardio version. They've tried medications. The patient's AFib is just persisting. So at that point, they are going to do the pacemaker and then they're going to do that planned AV node ablation to put that patient in complete heart block. And then the hope is to control the arrhythmia at that point with the pacemaker system itself. So yes, complete heart block is required in an AV node ablation. All right. I know I'm three minutes over. I will definitely compile the remaining questions and get that in a Q&A document so we can have that as an additional resource for everybody that joined today. I do appreciate everybody's time. Please make sure you register for the next series. I will be presenting that in three weeks from today and I will be talking about our EP device implant services. All right. I appreciate everybody's time today and see you in three weeks.

Jamie Quimby

Director of Coding

MedAxSAM

EP studies

ablations

anatomy

physiology

ablation techniques

AV node ablation

pulmonary vein isolation

medication testing

mapping

transeptal puncture