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3/18/2013

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Coding for Cardiovascular Procedures 2013

Presented by:

David Zielske, MD, CIRCC, CPC-H, CCC, CCS, RCC

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National Coding Standards Sources of information

– Centers for Medicare and Medicare (CMS)

– Provider Policy Manual (19.0)

– NCDs and LCDs from Medicare Administrative Contractors (MACs)

– American Medical Association (AMA), CPT Symposium, CPT Changes

– American College of Cardiology (ACC)

– Heart Rhythm Society (HRS)

– Society of Interventional Radiology (SIR)

– Other MAC’s LCDs

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Change Adds to the Complexity Continuous changes in coding rules & regulations

− CCI Edits, Pass Through Edits, MUEs (service unit edits)

− CMS, NCD, LCD, Policy Manual, and Physician Society Coding Manual Descriptions and Revisions

− HCPCS Level 2 Codes (Medicare)

• GO275, GO278 (Non-selective renals or ilio-femorals at time of cath)

• Hospital only G codes

C9600-C9608 (Drug Eluting Stent Placement Procedures)

− Category 3 Codes

• 0024T – DELETED 7/2007, use unlisted code 93799

• 0075T (Intrathoracic Common Carotid/Extracranial Vertebral Stent Placement, initial vessel, extended until January 2015)

• 0262T – Percutaneous Pulmonary Valve (Melody Valve) placement (7/2011)

• 0281T – Percutaneous Transcatheter Closure of Left Atrial Appendage (1/2012)

• 0291T-0292T – Optical Coherence Tomography, Coronary Arteries (1/2012)

• 0319T-0328T – Subcutaneous Defibrillator Procedures(1/2013)

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Recommendations for Physician Dictations of Cardiac Catheterization and Intervention

State the history (acute MI), prior surgeries or interventions, medical necessity for diagnostic and interventional procedure, reasons for repeat diagnostic study after prior Angio/CTA/MRA .

State the vascular access site(s).

State the vessels catheterized, describing the catheter tip location, and any variant anatomy or surgically created grafts.

State heart pressures and chambers entered, injected, and imaged.

State the vessels injected, the areas imaged (for medical necessity) with interpretation of findings, along with specific documentation of degree stenosis and exact locations of the lesions treated, including CTO and graft documentation.

State the interventions (including IVUS, FFR, OCT, etc., with findings and % stenoses) performed and any complications or additional treatments provided.

State the specific devices and specialty supplies used during the procedure.

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Recommendations for Physician Dictations of Peripheral Interventions

State the history, medical necessity, prior interventions, reasons for repeat diagnostic study after prior catheter angiography/CTA/MRA

State the vascular access site(s) and what is performed (diagnostic angio/intervention via each access site and timing

State the vessels catheterized, describing the catheter tip location, and any variant anatomy

State the vessels injected, the areas imaged (for medical necessity), interpretation of findings, specific documentation of percentage stenosis, exact anatomic location of the lesions and description of any normal vessels in between the stenoses along with bridging lesions

State the interventions and adjunctive procedures performed. Also any complications or additional treatments provided

State the specific devices and specialty supplies used during the procedure

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Anatomy & Physiology

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Diagnostic Cardiac Catheterization

Cardiology Coding

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Diagnostic Catheterization 3 codes for heart caths without coronaries. Rt, Lt, or Rt and Lt

2 codes for coronary angiography without a heart cath

3 codes for native coronary angiography with a heart cath

3 codes for graft angiography (includes natives) with a heart cath. The “graft” codes are used when IMA injected as “potential” graft

3 add-on codes for injection procedures: right heart chambers, supravalvular aorta, and pulmonary arteries

3 add-on codes for: transapical or transseptal approach, drug administration with hemodynamics, and physiologic exercise study.

3 add-on codes for use with congenital heart codes 93530-93533: native coronary angiography, graft angiography (including natives), and left atrial/ventricular injection and imaging

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Diagnostic Catheterization Only bill one primary cardiac catheterization code (93451-93461 or 93530-

93533) per session.

May bill “add on” codes with primary heart cath codes

Add on codes 93463, 93464, 93566, 93567 and 93568 can be billed with ANY of the heart cath procedures if performed. 93462 is not coded with congenital caths.

Add on codes 93563, 93564 and 93565 can ONLY be billed with congenital heart caths.

Codes for native coronary arteries, grafts, right or left ventriculography/atrial angiography require selective catheter placements. Pulmonary artery and aorta do not.

“with graft” codes can be for native IMA’s prior to surgery

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Diagnostic Catheterization All cardiac catheterization procedures include:

– conscious sedation

– sheath placement

– catheter introduction, positioning and repositioning with the use of multiple catheters

– recording of pressures in chambers and vessels (if done)

– intracoronary arterial injection of medications

– final evaluation and report

– angiography for closure device placement and the actual closure device placement

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Diagnostic Catheterization Right heart catheterization – 93451 – includes:

- Catheter placements in RA, RV, PA and wedge locations

- Blood samples to determine blood gases and cardiac output, (including oxygen saturations, wedge pressures, thermodilution studies, etc.)

- Right atrial or ventricular angio is coded separately (+93566)

- Pulmonary angiography is coded separately (+93568)

- Do not additionally code Swan Ganz catheter placement (93503) as right heart catheterization procedure uses this catheter as an integral component to perform the test (do not bill with any other diagnostic heart catheterization codes)

- See codes 93456-7 if coronary angiography done

- Use 93530 for congenital right heart catheterization

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Diagnostic Catheterization Left heart catheterization – 93452

− Defined as left heart hemodynamics. Requires placement of a catheter into a systemic heart chamber (left ventricle or atrium).

• Left ventricular systolic and end-diastolic pressures

• Left ventricular injections and ventriculography are bundled.

• Percutaneous or cut-down technique

• See codes 93458-9 if coronary angiography done.

• Use 93452 for congenital left heart catheterization (per AMA response, you can use the non-congenital code if congenital, but you cannot use congenital code if non-congenital).

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Diagnostic Catheterization Right and Left heart catheterization - 93453

- Defined as right and left heart hemodynamics and requires catheter placements into right and left heart chambers

- Right atrial or ventricular angio is coded separately (+93566)

- Pulmonary angiography is coded separately (+93568)

- Left ventriculography is bundled if performed

- Do not additionally code Swan Ganz catheter placement (93503)

- See codes 93460-61 if coronary angiography done

- Use codes 93531-93533 for congenital right and left heart cath

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Diagnostic Catheterization Coronary angiography without heart cath

- Coronary angiography – 93454

- Coronary angiography with grafts – 93455

Coronary angiography with right heart cath



Coronary angiography with left heart cath


- Coronary angiography with grafts - 93459

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Diagnostic Catheterization Coronary angiography with right & left heart cath



Right chamber angiography – +93566 (add on code)

Supravalvular aortography – +93567 (add on code)

Pulmonary angiography – +93568 (add on code)

Do NOT bill +93563, +93564 or +93565 with above listed adult catheterization codes. These codes are ONLY used with congenital heart cath codes 93530-93533.

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Diagnostic Catheterization Transseptal puncture via intact septum or transapical left ventricular

puncture approach for LHC: +93462 (add on code). Do not use with congenital heart catheterization codes or A FIB ablation by pulmonary vein isolation . Only bill once per session even if double transseptal necessary.

Drug administration to assess cardiac hemodynamics (e.g., inhaled nitric oxide, nipride infusion, oxygen) before, during and after, and repeat – +93463 (add on code). Do not use for coronary artery drug administration (e.g., nitroglycerin, adenosine). Only bill once per session.

Physiologic study to assess cardiac hemodynamics (e.g., leg or arm exercise) before and after heart cath. +93464 (add on code). Only bill once per session.

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Congenital Heart Catheterization Right heart catheterization only – 93530

Left heart catheterization only (congenital or non-congenital) - 93452

Right & retrograde left - 93531

Right & transseptal left (intact) - 93532

Right & transseptal left (existing) – 93533 — Once diagnosed as a congenital cardiac patient, catheterization procedures are always

considered congenital for coding purposes (including heart transplants) unless ALL aspects of congenital heart disease have been removed, then it reverts to “regular” heart catheterization codes

— Bicuspid aortic valve, patent foramen ovale, anomalous origin of coronary arteries and mitral valve prolapse are NOT considered congenital heart disease for coding purposes. Cardiomyopathy, Rheumatic heart disease and Kawasaki’s disease are also non-congenital disease.

Codes 93532 and 93533 include “with or without retrograde LHC”.

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Diagnostic Catheterization Congenital Heart Catheterization add-on codes

− Coronary angiography, congenital – +93563

− Coronary w/ bypass grafts, congenital - +93564

− Left atrium/ventricle during congenital – +93565

− Right atrium/ventriculography – +93566

− Supravalvular aortography – +93567

− Pulmonary angiography – +93568

− Nitric Oxide Study (pre and post studies) - +93463

− Exercise Study (pre and post studies) - +93464

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Injection of drugs directly into the coronary arteries is bundled (do not use +93463 or 37202).

Venous infusions during coronary intervention are bundled (the drug may be billed separately). Do NOT use +93463 or 92977 with intervention.

Closure device angiography and placement is bundled with all cardiac catheterization procedures. Do not bill 75710, 75736, 75774 or G0278 for imaging related to closure device placement.

Diagnostic Catheterization

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Charge separately for intravascular Doppler (FFR – 93571, 93572).

Charge separately for near infrared spectroscopy (NIRS - 0205T).

Charge separately for optical coherence tomography (OCT - 0291T, 0292T).

Charge separately for intravascular ultrasound (IVUS - 92978, 92979).

— All of the above need “findings” in the documentation.

Charge separately for any coronary artery intervention.

Charge separately for RA/RV, Ao, and pulmonary angiography.

Charge separately for transseptal or transapical approach, pharmacological, or physiological testing with heart catheterization.

Charge separately for peripheral imaging S&I codes, catheter placements and interventions. (Use “G” codes for non-selective diagnostic renal and ilio-femoral angiography at the time of cardiac catheterization unrelated to closure device placements.)


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Non-cardiac imaging performed with a heart catheterization

– G0275 – Non-selective Renal(s)

• Includes catheter placement and S&I

• If the renal arteries are selected, do not code G0275 (per CMS 1/2013, version 19.0 provider policy manual, “renal artery angiography at the time of cardiac catheterization should be reported as HCPCS code G0275 if selective catheterization of the renal artery is not performed”, “If it is medically necessary to perform selective renal artery catheterization and renal angiography, HCPCS code G0275 should not be additionally reported”.)

• GO275 edits 36251-36254. Do not bill both together.

• Many “selective renals” (36251-36254) are not medically necessary (per LCD’s) and may be refused payment by payers.


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Non-cardiac imaging performed with a heart catheterization

– G0278 – Non-selective Ilio-femoral (oblique views of the pelvis)

• Includes catheter placement

• Includes S&I

• Do not code G0278 for closure device placement angiography (per Provider Policy Manual 19.0).

• Code GO278 is a zero edit with 75716. Do not bill both together.


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Diagnostic Catheterization Case 1: PROCEDURE: A 6 Fr sheath is placed in the right femoral artery. Selective coronary angiography is performed with #4 Judkins left and right catheters. Selective left internal mammary angiography along with selection of 3 vein bypass graft is performed. An angulated pigtail is used for left heart cath and ventriculography. Aortography is performed with the same catheter to evaluate for aortic valve disease. Peripheral angiogram is performed for closure device evaluation. The CFA is 6mm without stenosis. RESULTS:

LC : 90% left main proximally. There is 60% stenosis of the LC.

LD: Occluded at its origin.

RC: 99% origin stenosis. 20-30% stenosis is seen distally in the PDA.

IMA(left): Patent proximally and distally.

Vein grafts: LC and diagonal are occluded. Graft to the RCA is widely patent.

LEFT HEART CATH and VENTRICULOGRAPHY: Systemic pressures are normal. No systolic gradient across the aortic valve. LVED is 15. EF is 35% with decreased septal wall motion.

Aorta: Aortic root is dilated, but there is no aneurysm or aortic valve reflux.

PERIPHERAL ANGIOGRAM: This is done through the short 6 French introducer and shows the introducer entering the mid common femoral artery. No significant iliac or femoral vascular disease is seen. A Mynx closure device is placed.

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Diagnostic Catheterization Case 1 Codes:

93459 – Coronary angiography, native and grafts, with LHC, with LV angiogram if performed

Closure device imaging and placement are bundled.

93567 – Supravalvular aortography

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Diagnostic Catheterization Case 2:

BRIEF HISTORY: A 62-year-old lady who was admitted because of worsening chest pain with EKG changes of ischemia.

PROCEDURE:

Left heart catheterization.

Right heart catheterization.

Coronary arteriography.

Left ventriculography.

Cardiac output examination.

TECHNIQUE: Using a modified Seldinger technique, sheaths are placed in both the right common femoral vein and artery.

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Diagnostic Catheterization Case 2 (continued):

6 French Judkins catheters are placed in the right and left coronary arteries for coronary angiography in multiple projections. A pigtail catheter is placed into the left ventricle with ventriculography done. The patient has severe aortic valve disease requiring surgery; therefore, it is decided to do a right heart catheterization also. Right heart pressures, pulmonary pressures, oxygenations, cardiac output and index are performed. Right atrial injection along with selective R & L pulmonary angiography performed due to low oxygenations suggesting R to L shunt.

RCA: 70% lesion in the proximal RCA. 90% lesion in the proximal PDA.

Left Main: There is an ostial lesion present; this is about 80%.

LC: There is an 80% lesion seen in the first obtuse marginal.

LD: There is a long 80% lesion seen in the proximal portion.

RIGHT ATRIAL ANGIOGRAPHY: No evidence of right to left shunt.

PULMONARY ANGIOGRAPHY: No evidence of pulmonary artery fistula.

VENTRICULOGRAPHY: Left ventriculography shows normal size and normal contraction of the left ventricle. EF is 40%.

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RESULTS HEMODYNAMICS:

SITE PRESSURE

1. Pre-angio: AO 160/80

LV 155/20

RV 37/12

2. Post-angio AO 156/70

LV 160/27

RA 7 mmHg (mean)

PA 40/12/25

PCW 15 mmHg (mean)

Cardiac output is 4.83. Cardiac index is 2.31. There is no gradient across the aortic valve or pulmonic valve demonstrated.

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93460 – Coronary angiography, with right and left heart catheterization, with left ventriculography

93566 – Right atrial angiography 93568 – Pulmonary angiography

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Peripheral at Time of Heart Cath Case 3: Abdominal aortography from high catheter position (to look at renals) and oblique pelvic angiography from low aortic catheter position, (to look at iliacs) all done during a a heart catheterization.

GO275 – Nonselective renal angiography at the time of cardiac cath

GO278 – Nonselective ilio-femoral angiography at the time of cardiac cath

**Catheter placement aorta is bundled. Also bill the appropriate heart catheterization code.

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Peripheral Case 4: Abdominal aortography from high catheter position and oblique pelvic angiography from low aortic catheter position for aortic aneurysm evaluation during a heart catheterization.

75630-59 – Aorto-ilio-femoral angiography, S&I

**Also bill the appropriate heart catheterization code.

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Peripheral and Heart Catheterization Case 5:

Left heart catheterization: Ventriculography and left sided hemodynamics are performed. Coronary angiography with selective imaging of the right and left coronary arteries is performed. The catheter is withdrawn into the aorta and placed above the renal arteries. An injection is performed with imaging of the abdominal aorta with attention to the renals. The catheter is withdrawn to the bifurcation and advanced to the contralateral common femoral. An injection with imaging of the left leg to a level just above the ankles. Via the right femoral sheath, similar injection and imaging is done.

The coronary arteries show 90% RCA stenosis proximally. A DES is placed with 0% residual. The LV injection shows 55% EF, normal contractility and normal hemodynamics. The abdominal aorta has minor plaque but no aneurysm or stenosis is identified. The renal arteries show 70% stenosis on the left, normal right side.

Bilateral lower extremity: The right iliac artery shows a 60% narrowing in the proximal vessel. The right superficial femoral, popliteal and tibial arteries are normal. The left leg shows stenoses of 80% at Hunter’s Canal and 40% in the mid anterior tibial with occluded peroneal and posterior tibial arteries.

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Peripheral and Heart Catheterization Case 5 Codes:

93458-59 – Coronary angiography with left heart catheterization, including left ventriculography

C9600-RC – DES in RC (MD uses 92928-RC) G0275 – Non-selective renal angiogram 36246-59 – Catheter placement to contralateral common femoral 75716-59 – Bilateral lower extremity angiogram, S&I

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PROCEDURES: Patient with abnormal stress test, TIA’s and abnormal vertebral Doppler. Coronary angiography, left ventriculography, aortic arch angiography, bilateral cervical and cerebral carotid angiography, right vertebral angiography, left subclavian angiography and left subclavian stent. Via right femoral approach bilateral selective coronary arteriograms are performed. A 6 French pigtail catheter is guided across the aortic valve without difficulty and left heart hemodynamics and ventriculography are performed.

The catheter is then pulled back and cervicocerebral arch angiogram is done. Selective catheter placement into the right and left common carotid arteries, followed by injection and imaging of these vessels. The right vertebral and left subclavian arteries are also selectively catheterized and fully imaged (to the hand on the left).

FINDINGS: The LV has 55% EF and contractility is normal. The left main, LAD and LC are normal. The RC shows a 40% stenosis in the proximal portion.

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Peripheral and Heart Catheterization Case 6 (continued):

The proximal great vessels are patent with normal anatomy. The right common carotid artery bifurcation shows an 80% eccentric lesion. The left common and internal carotid arteries appears normal. The intracranial vessels are normal bilaterally. The left subclavian shows 90% stenosis proximally. The left vertebral artery does not fill via this injection. The right vertebral injection shows normal right vertebral artery and flow up the basilar artery. There is slow retrograde flow down the entire left vertebral via this injection consistent with vertebral steal phenomena.

Following the diagnostic study, a stent is placed across the left subclavian stenosis. This is balloon dilated to 7mm. Follow-up imaging shows good flow in the left subclavian with restoration of antegrade flow up the left vertebral.

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93458 37205 75710-59 36223-50 75960 36226 36215-59

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Cervicocerebral Codes: Abbreviated 36221 – Arch (catheter in arch)

36222 – Selective neck (catheter in CCA or innominate)

36223 – Selective brain (catheter in CCA or innominate)

36224 – Superselective brain (catheter in ICA)

36225 – Selective vertebral (catheter in subclavian or innominate)

36226 – Superselective vertebral (catheter in vertebral)

+36227 – Selective external carotid (catheter in external carotid)

+36228 – Superselective (catheter in MCA, ACA, PCA, Basilar, or other intracranial branches)

All codes are unilateral, use -50 or -59. Arch is bundled if 36222-36226 used. Only one carotid code per side. Only one vertebral code per side. Use 36228 up to 2X per side. Do use 76937, 76376, 76377. Do not use 75774. Catheter placements bundled with diagnostics, NOT when intervention only.

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HISTORY: 72yo with prior CABG, now with severe hypertension, recurrent angina and abnormal carotid Doppler with TIA’s. PROCEDURE: A 6 Fr sheath is placed in the right femoral artery. Selective coronary angiography is performed with #4 Judkins left and right catheters. Selective left internal mammary angiography along with selection of 3 vein bypass graft is performed. An angulated pigtail is used for left heart cath and ventriculography. Due to pressure gradient across the valve, ascending aortography is performed with the same catheter to evaluate for aortic valve disease. This is followed by selective right and left common carotid and bilateral vertebral artery catheter placement with injection and imaging of the cervical and cerebral carotid arteries and the vertebrobasilar system bilaterally. Non-selective abdominal aortography to look at the renal arteries is followed by a femoral angiogram for closure device placement. After discussion with patient and family, angioplasty followed by 4mm stent in the right coronary artery origin and a 3mm stent in the PDA were performed. The right cervical common/proximal internal carotid artery was then selected and a proximal embolic protection device was deployed. Pre-dilation of the stenosis in the carotid was performed followed by deployment and post-dilation of a 6mm carotid stent. Right renal stent is also placed. Angiomax was given as a bolus followed by a continuous IV infusion for the following 18 hours. Sheath was removed. Closure device is placed.

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RESULTS:

LC : Occluded at its origin.

RC: 99% origin stenosis. 90% stenosis is seen distally in the PDA.

IMA (left): Patent proximally and distally to the LD.

VEIN GRAFTS: LC is patent. Graft to the RCA is occluded proximally.

LEFT HEART CATH and VENTRICULOGRAPHY: Systemic pressures are normal. LVED is 15. EF is 35% with decreased septal wall motion on ventriculography.

Aorta: Aortic root dilation with associated jet of aortic valve stenosis is present

CORONARY INTERVENTION: Wire, followed by 3mm balloon angioplasty and 4mm non-DES placement across the proximal RC stenosis and 3mm non-DES stent in the PDA w/o complication.

PERIPHERAL ANGIOGRAM and INTERVENTION: There is an aberrant right subclavian artery. There is no common carotid or subclavian stenosis. Selective bilateral cervical, cerebral and vertebral angiography shows 90% proximal right internal carotid stenosis. Right carotid angioplasty and stent is then performed with proximal EPD w/o complication. The right renal artery is 90% stenosed so a 6mm balloon expandable stent is placed proximally across the stenosis. The right iliofemoral angiogram is normal so a Starclose closure device is placed.


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93459-59 – Coronary angiography, with grafts, with left heart catheterization, including left ventriculography

93567 – Supravalvular aortography (aortic root injection), including injection and imaging 92928-RC – Non-DES right coronary artery 92929-RC – Non-DES PDA of RC 36223 – Unilateral selective left carotid cervical/cerebral angiography 36226-50 – Bilateral selective vertebral angiography 37215 – Right common carotid stent placement G0275 – Non-selective renal angiography at the time of cardiac catheterization 36245-59 – Selective right renal artery catheter placement 37205 – Right renal artery stent placement 75960 – Right renal artery stent placement S&I **Closure device angiography and placement is bundled. Consider -59 for second vertebral.

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Variant Arch Anatomy – Aberrant Right Subclavian Artery Transfemoral Approach

First order

Second order

Third order

Non-selective

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History: Abnormal stress test, angina, intestinal angina, severe hypertension with abnormal renal doppler. Bilateral 1-block calf claudication.

– Left heart catheterization with ventriculography.

– Coronary angiography.

– Bilateral selective renal and visceral angiography.

– Bilateral selective lower extremity angiography

– Right femoral access with perclose placement.

Left heart catheterization. Via right femoral puncture, a catheter is advanced to the ascending aorta. Ventriculography is performed using power injection of contrast agent. Pressures in the left heart were obtained.

Coronary angiography. A catheter is advanced to the right and left coronary arteries for selective native vessel imaging.

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Peripheral and Heart Catheterization Case 8 (continued): Peripheral angiography: A catheter is placed into both the right and left renal arteries and contrast is injected. SMA and celiac angiography is also performed after selective catheter placements into these vessels. The catheter is pulled down to the bifurcation and advanced over the horn into the left common iliac. Selective imaging of the left leg to the foot is performed. The catheter is pulled back to the right iliac and imaging of the right leg performed.

Renal Angio: Normal left renal, 80% stenosis right renal origin.

Visceral Angio: SMA shows 90%stenosis, celiac shows 40% stenosis.

Lower extremities: There are minor luminal irregularities due to atherosclerosis in the left iliac artery. Both superficial femoral arteries are occluded at Hunter’s Canal. The left distal popliteal re-occludes. A short proximal left PFA stenosis of 90% is also noted. Trifurcations are patent bilaterally.

Intervention: Guiding catheter was placed and primary stents were placed in the right renal origin and SMA. The stent placements required a new brachial approach due to angulation of the vessels. The contralateral distal left SFA (via the right femoral sheath) was treated with laser atherectomy. The popliteal occlusion was crossed with a Lumend device, followed by balloon angioplasty (5mm) but this promptly occluded requiring placement of a 6mm Viabahn stent. The proximal PFA stenosis was treated with 4mm angioplasty alone. Perclose was placed.

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93458 – Coronary angiography with left heart cath, including left ventriculography

36252 – Bilateral selective renal angiography 36245-59 x 2 – 1st order select below diaphragm (celiac, SMA) 75726-59 x 2 – Visceral angiogram, S&I 75716-59 – Bilateral extremity arteriogram, S&I 36245-59 x 2 – 1st order (renal, SMA from axillary approach for intervention) 37205/75960 – Right renal stent 37206/75960-59 – SMA stent 37227 – SFA/PFA/Popliteal artery angioplasty, atherectomy, and stent placement

(includes all three types of interventions in any or all of the femoral popliteal vessels, includes all catheter placements for these vessels, includes closure device placement)

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Interventional Cardiology

Cardiology Coding

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Interventional Cardiology IVUS Intravascular Doppler Angioplasty Atherectomy Stent Placement Brachytherapy Thrombolysis Thrombectomy Alcohol Ablation and Septal

Embolization

ICE

Valvuloplasty

Heart Valve Repair/ Replacements

Septal Defect Repair

PDA Closure

Coronary AV Fistula

Left Atrial appendage ablation

Pericardiocentesis

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Interventional Cardiology Native Coronary Artery Revascularization

DELETED CODES

CPT 92982 – Angioplasty, initial vessel

CPT 92984 – Angioplasty, each additional vessel

CPT 92995 – Atherectomy, initial vessel

CPT 92996 – Atherectomy, each additional vessel

CPT 92980 – Stent placement, initial vessel

CPT 92981 – Stent placement, each additional vessel

HCPCS G0290 – Drug eluting stent, initial vessel

HCPCS G0291 – Drug eluting stent, each additional vessel

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Interventional Cardiology Concept for new Coronary Interventions Guidelines are similar to lower extremity endovascular revascularization codes, but

not identical.

Five major coronary arteries, not three. Modifiers are LM, LC, LD, RI, RC.

We code for interventions in the five major coronary arteries, AND up to two additional branch interventions in LC, LD, and RC.

Code Grafts separately (in addition to intervention via the same native major coronary artery orifice [base vessel], includes EPD.)

Revascularization procedures for grafts, acute Mis, and CTOs include any combination of angioplasty, atherectomy, and stent.

Hospital Medicare coding uses C9600-C9608 for DES use.

No change for bridging lesions, temporary pacer use, catheter bundling, diagnostic documentation and use of mechanical thrombectomy. Acute MI treatment includes aspiration/EPD.

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Interventional Cardiology Native Coronary Artery Revascularization CPT 92920 – Angioplasty, single artery or branch

CPT 92921 – Angioplasty, each additional

CPT 92924 – Atherectomy, single artery or branch

CPT 92925 – Atherectomy, each additional

CPT 92928 – Stent placement, single artery or branch: C9600

CPT 92929 – Stent placement, each additional: C9601

CPT 92933 – Atherectomy with stent, single artery or branch: C9602

CPT 92934 – Atherectomy with stent, each additional: C9603

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Interventional Cardiology Grafts, Acute Occlusion and CTO

CPT 92937/C9604 – Graft revascularization, single vessel

CPT 92938/C9605 – Graft revascularization, each additional branch

CPT 92941/C9606 – Revascularization of acute occlusion during myocardial infarction, single vessel

CPT 92943/C9607 – Revascularization of CTO, single vessel, native coronary artery, branch or bypass graft

CPT 92944/C9608 – Revascularization of CTO, each additional native coronary artery, branch or bypass graft

Codes 92937-92944 include any combination of stent placement, atherectomy, and angioplasty.

Revascularization codes 92937-92944/C9604-C9608 include any combination of stent placement, atherectomy, and angioplasty.

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Interventional Cardiology Basic Guidelines

A stent is a stent, a balloon is a balloon, and atherectomy can be rotational, laser, side cutting, or pulverization.

Current DESs include ION, TAXUS, ENDEAVOR PROMUS, XIENCE V, and RESOLUTE INTEGRITY for codes C9600-C9608.

All coronary artery interventions include temporary pacemaker insertion (zero CCI edit 1/2013 for physicians, one edit for hospitals).

Coronary artery revascularization includes intracoronary thrombolysis.

Modifiers required per LCDs or “claim may be returned as incomplete” (LM, LC, LD, RI, RC).

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Diagnostic angiography performed at same session may be coded separately (requires -59).

— Must not have prior diagnostic angiogram and decision to perform intervention is based on this new angiogram, OR:

— There must be new clinical indication, documentation of poor visualization of anatomy/pathology or change in clinical symptoms during the procedure outside the target zone.

— Must always meet new medical necessity to code for another diagnostic coronary angiogram.

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Interventional Cardiology Vessel Interventions

Hierarchy per CPT Symposium Nov. 16, 2012

92943 = 92941 > 92933 > 92924 > 92928 > 92937 > 92920 (e.g., If stent proximal RC graft and CTO of distal RC graft, use 92943 as higher level intervention than 92937 and OK per CPT description for coronary artery, coronary artery branch or bypass graft. If CTO of native RC and stent with atherectomy is performed in RC, use 92943 instead of 92933)

CTO = Acute MI > Atherectomy with Stent Placement > Atherectomy > Stent Placement > Graft Revascularization > Angioplasty

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Interventional Cardiology Vessel Interventions

The five major coronary arteries recognized for base codes are: the Left Main (LM), Left Circumflex (LC), Left Anterior Descending (LD), Ramus Intermedius (RI), and Right Coronary (RC).

There is one base code submitted per major coronary artery or branch intervention. Use the hierarchy for each vascular distribution and code the highest level intervention (major OR branch) as the “base” code, and the lower level intervention (major OR branch) for any additional interventions .

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Interventional Cardiology Additional Vessel Interventions

Branches are coded to the major coronary arteries; however, the left main and ramus do NOT have recognizable branches.

Up to two branches (e.g., diagonals, obtuse marginals, PDA, posterolateral branches) can be additionally coded for interventions per major coronary artery (LD, LC, RC).

Additional intervention codes are submitted when these interventions are performed in branches of a base vessel (when the base vessel has already had an intervention).

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Interventional Cardiology Additional Branch Interventions

Additional interventions are described by codes 92921, 92925, 92929, 92934, 92938, and 92944.

Hierarchy of additional interventional codes per CPT: 92944 = 92938 > 92934 > 92925 > 92929 > 92921

CTO = graft revascularization > atherectomy with stent placement > atherectomy >stent placement > angioplasty

There is no code for additional acute MI occlusion revascularization, however “additional” codes for branch interventions (angioplasty, stent, atherectomy, CTO, and graft still apply if done).

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Guidelines are similar to lower extremity endovascular revascularization codes, but not identical.

The Left Main is its’ own major vessel, as is the ramus.

For common procedures (92920-92934): atherectomy with stent placement supersedes atherectomy, which supersedes stent placement, which supersedes angioplasty.

Angioplasty is included in ALL interventions, if performed.

Only code one intervention for bridging lesions treated with one device.

Code two interventions for treatment of bifurcation lesions.

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Acute MI treatment (92941) included thrombolysis, embolic protection, and aspiration thrombectomy.

Acute MI treatment does NOT include mechanical thrombectomy (92973) which can be separately coded when documented. This would be with AngioJet device.

Acute MI treatment (92941) includes revascularization by any combination of angioplasty, atherectomy, and stent placement.

If additional branches of the same major coronary artery are treated for stenosis at the same setting as an acute MI treatment, use the additional intervention code that best describes the intervention performed.

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Interventional Cardiology: Grafts Use as many “graft” base codes as different graft origins are

selected and intervention performed on.

Interventions through bypass grafts are coded to the major coronary artery the graft is anastomosed to.

Use hierarchy for Acute MIs and CTOs performed in graft vessels.

If one segment of a major native coronary artery is intervened on via the native vessel access and another segment via a graft access, two base codes should be submitted (graft and native coronary arteries). Must be different segments treated.

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Interventional Cardiology: Grafts Use graft codes for any interventions performed via graft

access.

Use “additional” graft codes for Y graft branch interventions.

Use “additional” graft codes for native vessel branch interventions performed through a graft access. If intervention is done in the artery the graft is attached to, it is included with the original graft intervention. If a branch of the native has intervention, add code 92938.

All graft interventions include use of embolic protection device.

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Interventional Cardiology Intravascular Ultrasound (Coronary Only)

— Initial vessel – +92978 [once per heart]

— Each additional vessel – +92979 [up to 4 other major coronary arteries…not likely]

Intravascular Doppler/Pressure (FFR, Wavewire) (Coronary Only)

— Initial vessel – +93571

— Each additional vessel – +93572

Near Infrared Spectroscopy (NIRS. Lipiscan. Coronary Only. During dx evaluation and/or therapeutic intervention, including imaging supervision, interpretation, and report. Expires 1/2015)InfraReDx TVC imaging is combination of IVUS and NIRS for lipid detection

Each vessel – 0205T

Optical Coherence Tomography (Coronary Only, Expires 1/2017)

— Initial vessel – 0291T

— Each additional vessel – 0292T

Intracardiac Echo (ICE) - +93662

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Interventional Cardiology Thrombolysis

− Intracoronary infusion – 92975 (This is a catheter-directed, selective infusion. It is an inpatient only procedure and is not billable with intracoronary stent placement)

− Intravenous infusion - 92977 (e.g., 100mg TPA by ER nurse in IV)

− Do not use 92977 for IV Reopro, Angiomax, Integrillin, etc infusion during coronary intervention (bill with appropriate “J” codes)

CTO with Frontrunner

− Considered part of the subsequent intervention, not separately billable

Thrombectomy (e.g., AngioJet Catheter only. Not for aspiration catheters like Pronto, Export, etc., which are included in code 92941.

Each vessel – +92973 (add-on code, some payers do not allow with atherectomy or angioplasty “NGS”) (Use of a distal embolic protection device is considered part of the intervention. It is not a thrombectomy.)

Brachytherapy

– Each vessel – +92974

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Interventional Cardiology Endomyocardial Biopsy – 93505 (may code for a right heart catheterization

if meets medical necessity and not done just to guide the biopsy procedure. Do not bill with 75970)

Non-surgical septal reduction therapy – 93799 (alcohol ablation of septal hypertrophy in patients with HOCM, (hypertrophic obstructive cardiomyopathy), with necessary coronary angiography, with or without temporary pacemaker

Septal perforator coil embolization for treatment of septal hypertrophy – 93799

Coil embolization of coronary artery fistula – 37204, 75894,75898

Femoral Artery Pseudoaneurysm Treatment – 76936 (US compression) or 36002/76942 (US guided thrombin injection)

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Percutaneous Heart Assist Devices

Code 33990 – Insertion Impella Device (arterial only)

Code 33991 – Insertion Tandem Heart (arterial & transseptal venous)

Code 33992 – Removal of percutaneous VAD at separate session

Code 33993 – Repositioning of percutaneous VAD at separate session

Code 34812 is appropriate when “open” arterial exposure is necessary to place a “percutaneous” VAD (code 33990 or 33991).

Code 35226 or 35286 may be necessary for extensive repair or replacement of the access artery.

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Percutaneous Heart Assist Devices: Removal or Replacement

Use code 33992 with -59 modifier when the removal of a VAD is on same date of service as placement, but at a separate distinct session.

Do NOT use code 33992 when VAD removed at same session as placement.

Use code 33990 or 33991 when an old percutaneous VAD is removed and a new percutaneous VAD is placed (replacement).

Do NOT use code 33992 (removal of percutaneous VAD) when an existing VAD is removed and replaced with a new device. The removal is considered a bundled component with the new device placement.

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Percutaneous Heart Assist Devices: Repositioning

Use code 33993 with -59 modifier when the repositioning of a VAD is on the same date of service as the placement, but at a separate distinct session. This requires the use of imaging guidance.

Do NOT use 33993 when VAD repositioned at the same session as placement or when repositioning is performed without imaging.

Repositioning of a percutaneous VAD without imaging guidance is not a reportable procedure.

CAN REPORT PERCUTANEOUS VAD PLACEMENT WITH TAVR/TAVI

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Heart Assist Devices: Balloon Pumps PERCUTANEOUS APPROACH

Code 33967 – Intra-aortic balloon pump placement (percutaneous)

Code 33968 – Intra-aortic balloon pump removal (percutaneous)

“OPEN” FEMORAL APPROACH

Code 33970 – Intra-aortic balloon pump placement (open femoral)

Code 33971 – Intra-aortic balloon pump removal (open femoral)

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Interventional Cardiology Case 9:

PROCEDURE: Coronary angiography. Selective left main coronary angiography, PTCA/stent of left anterior descending artery. PTCA/stent to right coronary artery.

INDICATION: High-grade stenosis LD and RC arteries on angiography two weeks earlier, however the patient presents acutely with unstable angina, hypotension, symptomatic bradycardia and acute MI.

PROCEDURE: A temporary pacer is placed at the start of the procedure due to the symptomatic bradycardia. A 7 French sheath followed by an 7 French catheter is used to cannulate the left main and angiograms reveals an 80% stenosis of the first diagonal branch proximally. There is a separate 40% lesion noted in the mid portion of the left circumflex artery. Right coronary injection shows complete occlusion suggesting interval thrombosis.

INTERVENTION: An AngioJet catheter was used to remove thrombus (using mechanical thrombectomy) from the RC. Angiography after this shows an underlying 80% stenosis which is treated with a 3.5 x 15mm Resolute Integrity drug-eluting stent at 11 ATMS with excellent result. The LD lesion is stented using a 2.75 x 12mm Resolute Integrity drug-eluting stent. IVUS was performed at this site, demonstrating incomplete deployment of the stent. This was further dilated with a 3.0mm balloon. Patient was stable at the completion of the intervention.

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Interventional Cardiology Case 9 Codes:

93454 – Coronary angiography C9606-RC – Acute MI revascularization, initial vessel, right

coronary 92978-LD – IVUS 92973-RC – Coronary artery thrombectomy, right coronary C9600-LD – Coronary stent placement, each additional vessel,

left anterior descending artery **Use codes 92941-RC and 92928-LD for MDs.) **Temporary pacemaker is a zero edit with coronary intervention.

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Diagnostic Catheterization Case 10: HISTORY: 67yo with prior CABG, now with recurrent angina. PROCEDURE and FINDINGS: A 7 Fr sheath is placed in the right femoral artery. Selective native coronary angiography is performed with #4 Judkins left and right catheters. Selective left internal mammary angiography along with selection of 2 vein bypass grafts is also performed. A fistula is identified off the left IMA supplying the left upper lobe bronchial vasculature resulting in steal phenomena from the LD. FFR with WaveWire across this region confirms dramatic drop in flow beyond the fistula. The LC vein bypass graft is patent. The RC vein bypass graft is stenosed 90% proximally. An embolization with two 3mm coils is performed in the IMA branch fistula followed by repeat FFR showing normal velocities distally. Follow-up angiography of the IMA shows complete occlusion of the IMA branch fistula with good coronary perfusion to the LD distribution. Next, the RC saphenous vein bypass graft is selected and a distal embolic protection device is placed. A Promus DES is then deployed and the EPD removed. Follow-up angiography on the right shows complete occlusion of the native RC just beyond the distal SVBPG anastomosis consistent with development of an embolus or thrombus after placement of the SVBPG stent. An Export catheter is advanced to native RC and extensive thrombus is removed. There is questionable haziness at the native RC site post thrombectomy so IVUS is performed showing a severe dissection with 80% luminal loss. Three overlapping bare metal stents are placed across the site of dissection. Follow-up IVUS shows resolution of the dissection while follow-up angiography shows excellent flow and distal perfusion. The abdominal aorta and iliofemoral arteries were evaluated via a single injection as an AAA is noted.

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collateral

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93455 – Coronary angiography, with grafts C9604-RC – DES right coronary artery in vein graft (revascularization) 92978-RC – IVUS right coronary artery 93571-LD – Intravascular Doppler left internal mammary artery 37204 – Embolization branch of IMA at time of cardiac cath 75894 – Embolization S&I 75898 – Follow-up angiography post IMA embolization 75630-59 – Aortoiliofemoral angiography (for AAA evaluation)

**Code 92973 is not billable with aspiration catheters such as Export, Pronto, Diver, Fetch, etc. **MDs bill code 92937-RC . (If a branch rather than the main RCA is intervened on, use add-on code 92938.)

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Interventional Cardiology Case 11: PROCEDURE: Selective vein graft angiography to the right coronary artery, selective left main coronary angiography with rotablation of the left main and circumflex, PTCA of the left circumflex artery, stent implantation times three to the left circumflex artery, angioplasty and stent placement times two in 1st obtuse marginal.

INDICATION: New onset angina and shortness of breath. Known native right coronary artery occlusion from angiogram 1997. Aortic valve replacement 1997. Abnormal stress test one week ago showing a large, reversible defect.

DESCRIPTION OF THE PROCEDURE: A 7 French sheath is placed in the right common femoral artery. We cannulated using a 6 French catheter and selective angiograms are obtained of the saphenous vein graft leading to the right coronary artery showing that it is widely patent. Following this, a 7 French EBU 3.5 catheter is used to cannulate the left main coronary artery and angiograms show the left anterior descending artery to be diffusely diseased. Atherectomy of the Left Main was performed. Next, due to the intermediate narrowing in the native LAD, a wave wire is placed after 5000 units of intravenous heparin and a fractional flow reserve is calculated and measured 0.72. The left circumflex artery is also heavily calcified with severe diffuse disease with sequential 99% stenoses.

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Interventional Cardiology Case 11 (continued):

Following this, a decision was made to intervene on the left circumflex artery. The patient was given Heparin and ReoPro for anticoagulation. We elected to Buddy wire with a rota-floppy wire and were able to get it to the mid portion of the circumflex artery. We then performed rotablation utilizing 1.25 burr with three passes. Following this, we performed angioplasty in the left circumflex artery and the 1st obtuse marginal with a 2.5 x 15 mm balloon. We then deployed an Ion 2.5 x 15 mm stent in the mid left circumflex artery followed by two additional 3.0 x 15 mm Ion stents in the proximal left circumflex artery and two additional Ion stents in the OM. Final angiograms revealed TIMI II antegrade flow with no evidence of dissection and 0% residual stenosis. Perclose was placed.

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93455 – Coronary angiography, with grafts, closure device included

93571-LD – Intravascular Doppler 92924-LM – Atherectomy, left main C9602-LC – Stent and atherectomy in LC, initial vessel (use 92933-

LC for physician billing) C9601-LC – Coronary stent placement, additional branch vessel,

left circumflex OM1 artery (use 92929-LC for physician billing)

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PROCEDURE: Right and left heart catheterization with thermodilution cardiac output, selective coronary angiography and left ventriculography.

DESCRIPTION OF PROCEDURE: A 7 French Swan-Ganz thermodilution catheter is advanced serially through the right heart chambers. Pressures are measured followed by measurement of the cardiac output using the thermodilution technique. Pigtail catheter is used for left heart cath and ventriculography. 7 French #4 Judkins coronary catheters are advanced to the right and left coronary arteries and angiograms are taken in multiple projections. (CANNED DICTATION)

LEFT MAIN CORONARY ARTERY: The left main is normal.

CIRCUMFLEX: The left circumflex artery also has a stent in its proximal portion. There is 80% in-stent restenosis. This branch extends into marginal.

LAD: The LAD has a Y-shaped stent in it’s mid-area involving the diagonal branch. There is about 70% stenosis proximal to the stent.

RCA: The right coronary has a stent in its proximal portion. The right coronary artery has haziness suggesting narrowing in its proximal portion. The posterolateral branch has a 90% narrowing.

LEFT VENTRICLE: Prosthetic aortic valve in place. Left ventriculography not done.

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Interventional Cardiology Case 12 (continued):

INTERVENTION:

We used a 6 French JR4 for revascularization of right coronary artery. We used 0.014 Sport wire and gave 10,000 units of Heparin. Sport wire crossed the posterolateral branch and used a 2.5mm balloon for the angioplasty. Haziness was present in the proximal RC so IVUS was performed showing dissection and 70% stenosis. We then used a 3.5 x 13 mm drug-eluting Taxus stent and placed it in the proximal stenosis of the right coronary artery. We then crossed the LAD lesion. The proximal part of the LAD required angioplasty and this was done proximal to the stented area with a 3.5mm balloon. The left circumflex then underwent cutting balloon angioplasty in the area of intimal hyperplasia within the pre-existing stent with a 3mm Angiosculpt balloon.

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93456 – Coronary angiography, with right heart cath C9600-RC – Coronary stent placement, initial vessel, right

coronary artery (use 92928-RC for physician billing) 92921-RC – Angioplasty, additional branch, posterolateral

branch of right coronary 92920-LD – PTCA, left anterior descending artery 92920-LC – PTCA, left circumflex artery 92978-RC – IVUS coronary, right coronary artery

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PROCEDURE: Left main coronary artery stent placement. High risk patient.

DESCRIPTION OF PROCEDURE: Angiomax bolus and infusion was started via a peripheral IV. Via a left femoral approach, a 14 FR sheath was placed followed by placement of an Impella 2.5 device into the left ventricle. Via a right femoral approach, a sheath was placed and a guiding catheter advanced to the left main coronary artery. Using this as a guide, a wire traversed the 95% stenosis of the proximal left main coronary artery, followed by balloon angioplasty to 2mm followed by deployment of a 4.5mm drug eluting ION stent. IVUS after deployment shows good stent placement. Follow-up angiography shows complete occlusion of the LD secondary to embolus/thrombus. AngioJet catheter was immediately deployed. Thrombus was removed, however balloon maceration of thrombus was necessary along with thrombolytic infusion of 5mg TPA was given after thrombectomy. The Impella device was left in for cardiac support for another 4 hours. This was removed in the ICU.

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33990 – Percutaneous VAD via artery (Impella 2.5 device) C9600-LC – Coronary stent placement, initial vessel, left coronary artery (use

92928-LC for physician billing) 92978 – IVUS left main coronary artery 92973 – Coronary artery thrombectomy, AngioJet catheter

Do NOT code 92977 for Angiomax. Do NOT code 92975 for coronary artery thrombolysis as bundled with stent

placement. Balloon maceration of thrombus in the LD is part of coronary thrombectomy,

not a coronary artery angioplasty. If Impella is removed at a separate session, use code 33992-59.

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HISTORY: 82yo with chest pain, valvular disease, shortness of breath with rapidly worsening symptoms. PROCEDURE and FINDINGS: Via a right femoral approach, sheaths are placed into the femoral artery and vein. Complete diagnostic right and left heart catheterization is performed, along with selective native coronary angiography and left ventriculography. The study is completely normal with the exception of elevated right heart and pulmonary artery pressures so a pulmonary arteriogram is performed. This is performed selectively on the right and left, and demonstrates a large proximal nearly occlusive pulmonary embolus on the right. Percutaneous thrombectomy is performed on the right with removal of a large amount of thrombus, resulting in improved pressures. The catheter is pulled back and inferior venocavography is performed, showing some clot in the distal cava extending into the left iliac venous system. An IVC filter is then placed below the takeoff of the renal veins, above the thrombus and deployed. Sheaths are removed.

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93460 – Coronary angiography, with RT and LT heart catheterization, including left ventriculography

93568 – Pulmonary angiography (add-on code) 37184 – Primary arterial thrombectomy

PA percutaneous thrombectomy is considered non-covered for Medicare, NCD update Jan. 2010. Use -GZ modifier.)

37191 – Inferior vena cava catheter placement

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Percutaneous Valve Intervention

Cardiology Coding

Percutaneous Valve Intervention Aortic valvuloplasty – 92986

Mitral valvuloplasty – 92987

Pulmonary valvuloplasty – 92990

No code for Tricuspid valvuloplasty

Codes 33361-33365, 0318T and 33367-33369 for transcatheter aortic valve replacement (TAVR)

Percutaneous pulmonary valve (Melody Valve) replacement - 0262T

No code for percutaneous closure of para-prosthetic heart valve leak (93799)

No code for percutaneous treatment of mitral valve regurgitation using MitraClip (stapling device for mitral valve) or Mitral Contour System (cinching device in the coronary sinus)

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Sapien Valve

CoreValve

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Percutaneous Aortic Valve Replacement

Code 33361 – TAVR, percutaneous femoral approach

Code 33362 – TAVR, open femoral approach

Code 33363 – TAVR, open axillary approach

Code 33364 – TAVR, open iliac approach

Code 33365 – TAVR, open aortic approach (e.g., median sternotomy)

Code 0318T – TAVR, open trans-apical approach (approved 10/2012)

Do NOT use 34812 for open unilateral femoral access or 34834 for open brachial access as open surgical access is bundled.

Sapien valve, from Edwards Lifesciences, FDA approved on Nov. 2, 2011, for use in patients with calcified annulus, aortic stenosis and not a surgical candidate.

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Percutaneous Aortic Valve Replacement

Code +33367 – Cardiopulmonary bypass support for TAVR with percutaneous peripheral arterial and venous cannulations

Code +33368 – Cardiopulmonary bypass support for TAVR with open peripheral arterial and venous cannulations

Code +33369 – Cardiopulmonary bypass support for TAVR with central (e.g., aorta, right atrium, pulmonary artery) arterial and venous cannulations

Codes for cardiopulmonary bypass are add-on codes.

Only one type of cardiopulmonary bypass procedure can be submitted during TAVR. The appropriate code is added on to one of the TAVR codes (33361-33365, 0318T).

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Percutaneous Aortic Valve Replacement Temporary pacemaker placement (33210), catheter placements, balloon

valvuloplasty (92986), open vascular exposure (e.g., 34812), vascular closure, and valve placement, repositioning, and deployment are bundled.

Swan Ganz catheter placement (93503), all necessary aortic and left ventricular outflow tract measurements pre and post deployment, and imaging to guide, document and complete the procedure are bundled.

Diagnostic cardiac catheterization IS separately reportable with -59 modifier, but only if:

— a prior catheter based angiogram is not available and a complete diagnostic study is performed

— the prior study does not adequately visualize the involved anatomy or pathology

— the patient condition has changed since the prior study or

— *the patient condition changes during the procedure requiring repeat study*

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Percutaneous Aortic Valve Replacement Do code for TEE by separate physician during TAVR/TAVI.

Do code for any percutaneous coronary or other cardiac interventions necessary at the same session as the TAVR.

Do code for necessary placement of a percutaneous or open ventricular assist device at the time of the TAVR (e.g., 33990, 33991) .

Do code for necessary placement of a percutaneous or open aortic balloon pump at the time of TAVR (e.g., 33967, 33970).

Do code for cardiopulmonary bypass support at the time of TAVR (e.g., add-on code +33367, +33368, or +33369) .

TAVR requires two physicians. CPT codes for the primary procedure should use -62 modifier for physician billing (this refers to 33361-33365 and -318T). Codes 33367-33369 for the cardiopulmonary bypass support do not require -62 as that portion of the exam only requires one physician. IF only one physician performs the TAVR/TAVI and submits the bill without -62 modifier, it will be denied payment.

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0262T – Implantation of catheter-delivered prosthetic pulmonary valve, endovascular approach. (MELODY VALVE)

— Includes all congenital cardiac catheterization(s), intraprocedural contrast injection(s), fluoroscopic radiological supervision and interpretation, and imaging guidance performed to complete the pulmonary valve procedure.

Do not report 0262T in conjunction with 76000, 76001, 93563, 93566-93568, 93530).

0262T includes percutaneous balloon angioplasty/valvuloplasty of the pulmonary valve/conduit.

Do not report 0262T in conjunction with 92990.

Code 0262T includes stent deployment within the pulmonary conduit. Do not report 37205, 37206, 75960 for stent placement within the pulmonary conduit

Report 92928, 92929 (etc), 37205, 37206, 75960 separately when cardiovascular stent placement is performed at a site separate from the prosthetic valve delivery site.

Report 92997, 92998 separately when pulmonary artery angioplasty is performed at a site separate from the prosthetic valve delivery site.

Inpatient only C-status indicator in 2013

Percutaneous Pulmonary Valve Replacement

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Percutaneous Left Atrial Appendage Ablation

Left atrial appendage closure with implant, includes fluoroscopy, transseptal puncture, catheter placement, left atrial angiography, left atrial appendage angiography, including S&I – 0281T ― Do not code for transseptal approach (93462). ― Do code for left/right heart cath/pediatric heart cath,

ventriculography, etc, but ONLY if done for indications unrelated to the LAA closure.

― Inpatient only C-status indicator procedure in 2013 ― Watchman device was FDA approved 4/2009, others include

PLAATO, Amplatzer Cardiac Plug, PLACE System, & WaveCrest. We recommend 33999, 93462 and 93662 for Lariat procedure if transseptal ICE guided access is also performed.

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Percutaneous Left Atrial Monitor Insertion Insertion of left atrial hemodynamic monitor; complete system.

Includes the implanted communication module and pressure sensor lead into the left atrium, the transseptal access, any injection of contrast, imaging and radiological S&I – 0293T

Insertion of left atrial hemodynamic monitor; pressure sensor lead at the same time as placement of an ICD generator. Includes injection of contrast, imaging and radiologic S&I – + 0294T

HeartPOD Implantable Sensor Lead(ISL) is placed as part of the LAP (Left Atrial Pressure) Monitoring System.

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Cardiology Coding

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100

101

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103

Septal Defect Repair Closure of inter-atrial communication (patent foramen

ovale (PFO), atrial septal defect (ASD), and Fontan fenestration) – 93580

Closure of ventricular septal defect – 93581

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Septal Defect Repair Rules

Includes…

– Right and left heart catheterization

– Right and left atrial and ventricular imaging

– Supervision & interpretation for this imaging

– Access across the PFO into the left atrium/ventricle

Do not bill codes 93580 or 93581 with codes 93451-93453,

93455-93461, 93530-93533, or 93564-93566.

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Rules

Does NOT Include…

– Echocardiography

• Transthoracic

• Transesophageal – TEE

• Intracardiac – ICE

– Coronary (native), aortic, or pulmonary angiography

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Septal Defect Repair Case 15: HISTORY: A 15-year-old male with history cryptogenic stroke despite being on Coumadin therapy for Osler-Weber-Rendu syndrome. Noted to have PFO by TEE. Presents for evaluation and possible closure.

PROCEDURE: Right heart catheterization with thermal dilution cardiac output, selective right and left pulmonary arteriography, Pulmonary artery embolization, PFO Amplatzer occluder device (25 mm) placement, intra-cardiac echo monitoring.

DESCRIPTIONS OF THE PROCEDURE: Sheath was placed in the femoral vein. A Swan-Ganz thermal dilution catheter is advanced through the right heart chambers. Pressure tracings, measurements and measurement of cardiac output is performed.

Selective pulmonary angiography was performed bilaterally with a Grollman catheter. This showed a right lower lobe pulmonary AV fistula. Coils are noted in three previously treated left sided fistulae. This new fistula was crossed and two 3mm coils were placed. Follow-up angiography showed successful occlusion.

Amplatzer occluder is then advanced across a patent foramen ovale and deployed. ICE monitoring with bubble study before and after closure shows successful closure.

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Septal Defect Repair Case 15 Codes:

93580 – Percutaneous transcatheter closure of congenital interatrial communication with implant

93662 – Intracardiac echo (ICE) 93568 – Pulmonary angiography 37204 – Embolization of pulmonary AV fistula 75894 – Embolization S&I 75898 – Follow-up angiography after embolization

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Diagnostic Pediatric Cardiac Catheterization Considerations

Heart catheterization codes are specific for congenital heart disease, not patient age. Once congenital, always congenital. After transplant, if any residual documented congenital issues remain, use congenital codes.

Right heart catheterization, congenital – 93530 Left heart catheterization, congenital – 93452 Right and left heart catheterization varies by approach

– Via retrograde left, prograde right – 93531 – Via transeptal puncture 93532 – Via septal opening 93533 – Use 93463, 93464, 93563, 64, 65, 66, 67 and 68 once per patient encounter – Use 93568 for pulmonary vein selection and injection (usually done at the same time as

pulmonary artery angiography) – Add additional catheter placements, imaging and interventions performed in the

peripheral vessels

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General Recommendations for Physician Dictations

State the history (specific congenital cardiac abnormalities, prior surgeries, and percutaneous interventions) and medical necessity.

State all vascular access site(s), occluded vessels, and treatments.

State all vessels catheterized and selected, describing the catheter tip location and any variant anatomy, prior surgeries, shunts interventions.

State pressures and chambers entered, injected, and imaged

State the vessels injected, the areas imaged (for medical necessity) with interpretation of findings, along with specific documentation of degree stenosis and exact locations of the lesions treated (including peripheral diagnostics) and all vessels selected for embolization procedures, what these collaterals supplied, and was the imaging for guidance or diagnosis.

State the interventions performed and any complications or additional treatments provided (especially those involving the peripheral vessels).

State the specific devices and specialty supplies used during the procedure. Documentation of procedure duration.

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Pediatric Cardiac Catheterization Congenital Defects and Syndromes

Congenital heart defects (limited list)

– Ventricular septal defect (VSD)

– Atrial septal defect (ASD)

– Patent foramen ovale (PFO)

– Patent ductus arteriosus (PDA)

– Coarctation of the descending thoracic aorta

– Pulmonary artery atresia or stenosis

– Pulmonary, tricuspid or aortic valvular stenosis or atresia

– Single ventricle, hypoplastic right or left heart

– Truncus arteriosus

– Cardiomyopathy (non-congenital)

− AV canal with over-riding aorta and RVH = Tetralogy of Fallot

− Transposition of the great vessels

− Epstein’s anomaly (tricuspid)

− Anomalous origins of coronary arteries

− Septal hypertrophy

− Noonan Syndrome (pulm valve)

− Eisenmenger Syndrome

− Kawasaki disease (Non-congenital)

− Scimitar Syndrome (PAPVR)

− Rheumatic heart disease (Strep)

− Arrhythmia related to surgery or other conduction defects

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Hypoplastic Left Heart Syndrome

Coarctation of the Aorta

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Tetralogy of Fallot Transposition of the Great Arteries

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VSD Truncus Arteriosus

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Pediatric Cardiac Catheterization Considerations, Surgical Procedures

Open surgical repairs (limited list) – Open closure of atrial or ventricular

septal defects and AV canal – Bidirectional Glenn procedure – Extracardiac or Fenestrated

Fontan procedures – Norwood procedure – Blalock-Taussig shunt – Creation of pulmonary conduit,

homograft and valve replacement – Ligation PDA – Patch of coarctation

− Maze procedure

− Venous switch (intra-atrial baffle for TGA, Mustard and Senning procedures)

− Valvotomy

− Rastelli procedure

− Sanno modification

− Damus-Kaye-Stansel procedure

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115 Hypoplastic Left Heart

116

117 Extra Cardiac Fontan

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Pediatric Cardiac Interventional Considerations, Percutaneous Procedures

Atrial septostomy or septectomy (92992 or 92993) ASD or PFO closure (93580) Fontan fenestration closure (93580) VSD closure (93581) Creation of a Fontan fenestration with transeptal needle with stenting to maintain

this conduit (93799) PDA embolization or occlusion(93799 vs 37204, 75894, 75898) PDA stent placement (37205 or 37207, 75960 and 36215) Transthoracic insertion of catheter (33621) for stent placement (37207) Aorto-pulmonary or veno-venous collateral vessel embolization (use established

peripheral catheter placement and embolization codes) Aortic Coarctation angioplasty/stenting (35472, 75966, 37205, 75960, 36200?) Pulmonary artery angioplasty/stenting (92997, 92998, 37205/75960) Valvuloplasty (92986, 92987, 92990) EP ablations for arrhythmia (per EP section) Hypertrophic septal ablation (93799) Pulmonary valve replacement (Melody Valve), percutaneous (0262T) 118

119

Pediatric Aortic Arch Anomalies Aortic Arch types A, B, C

– Type A – Interruption just beyond the left subclavian artery

– Type B – Interruption between left subclavian and left common carotid artery

– Type C – Interruption between left common carotid and brachiocephalic artery

Interrupted aortic arch associated with VSD and PDA

– Requires surgery (aortic reconstruction, PDA occlusion) within a couple days

120

Pulmonary Artery Angioplasty PFO Closure

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121

Patent Ductus Arteriosus

PDA Occluder

Placement

122

Diagnostic Pediatric Cardiac and Peripheral Catheterization Considerations

Multiple accesses and approaches

Occluded vessels, duplicated vessels, variant and complex anatomy, prior surgery (both open and percutaneous)

Catheterizations and imaging of baffles, conduits and bypasses. These include multiple peripheral catheter placements outside the “normal” cardiac system (e.g., SVC, IVC, subclavian and hepatic veins, veno-venous collaterals, aorto-pulmonary collaterals, internal mammary, subclavian and carotid artery to pulmonary collaterals, PDA, descending thoracic aorta, and blood supply to intracranial and peripheral AVM’s, etc

Unusual diagnostic imaging in the cath lab requiring use of established radiology S&I codes (36221, 36222, 36223, 75710, 75716, 75726, 75756, 75774, 75820, 75822, 75825, 75827, 75889, 75898)

Cannot use 75756 with congenital heart catheterization

123

Pediatric Cardiac Case 16: 13yo with hypoplastic left heart syndrome with recent fenestrated Fontan. Increasing ascites and bradycardia. Right femoral vein access difficult so venogram shows occlusion. Left femoral vein approach used for Right Heart Cath. Hepatic wedge pressures (second order catheter placement) and venogram performed. Hepatic veins are patent. IVC-o-gram shows flow limiting stenosis near right atrial anastomosis. Pulmonary artery injection via Fontan anastomosis shows left PA stenoses in three separate branches. This was successfully catheterized and treated with angioplasty at all three separate and distinct sites of stenosis. Right atrial/Fontan injection and imaging performed. The subclavian vein injection shows large veno-venous collaterals. Largest of these was selectively injected showing an extensive venous collateral network, so this was embolized with multiple coils. Post-embolization angiography shows occlusion. SVC injection shows patent SVC and anastomosis with the right pulmonary artery. A balloon expandable stent was then placed across the IVC/Fontan anastomotic stenosis and fully dilated with excellent reduction of stenosis and improved venous inflow through the Fontan.

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124 Fenestrated Fontan

125

Pediatric Cardiac Case 16 Codes:

93530 92997 37205 93566 92998 75960 93568 92998 36012 36012-59 75889 37204 36005-59 75894 75820 75820-59 75825 75898 75827

126

Pediatric Cardiac Case 17:

4 yo with initial diagnosis of critical aortic stenosis treated with valvuloplasty during neonatal period. As ventricular function did not return, he was palliated with a Norwood procedure and recently with a bidirectional Glenn anastomosis. Due to reversal of flow seen in the flow across the Glenn on echo, he is referred for angiography and intervention as indicated.

Via a right femoral venous, then right jugular venous and femoral arterial approaches, a prograde right and retrograde left heart cath was performed with pressure and saturation data obtained. Aortography, followed by selective left subclavian, left internal mammary, left supreme intercostal (off the costocervical trunk) and left lateral thoracic artery injections and imaging. The Glenn was injected and pulmonary arteries imaged.

Findings: Femoral venography showed occlusion of the right iliac vein with IVC reconstitution. Jugular access was used for right heart cath and pressures with left heart cath findings in the log. Glenn injection shows to and fro flow in the pulmonary arteries with prominent washout on the left. Aortography shows left sided collaterals to the pulmonary arteries which were evaluated selectively and embolized with coil technique.

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127

128

Pediatric Cardiac Case 17 (continued):

Left subclavian angiography showed hypertrophied IMA, costocervical trunk and lateral thoracic arteries. A branch of the IMA was selected, imaged (systemic to PA collateral) and coil embolized. Follow up angiography showed occlusion. The same injections, imaging, findings and embolizations were performed in the supreme intercostal artery off the costocervical trunk and the left lateral thoracic arteries. Follow-up imaging was also performed of each vessel embolized. Follow up imaging of the pulmonary system showed improved flow and filling of the pulmonary arteries. Catheters were removed and hemostasis obtained.

129

Pediatric Cardiac Case 17 Codes:

93531 37204 – Embolization

93568 75894 – Embolization S&I

93567 75898 – Follow-up angiography

36005-59 – Injection for venography

75820 – Femoral venography

36217 – Left IMA collateral branch

36218 – Left supreme intercostal

36218 – Left lateral thoracic

75710 – Left subclavian angiography S&I

75774 x 3 – IMA, supreme intercostal, lateral thoracic angiography S&I (if for guidance, do NOT submit codes 75774)

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130

Electrophysiology

Cardiology Coding

131

Conduction System AV Node Ablation

132

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133

134

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136

137

Pacing and recording of cardiac rhythm

Induction (or attempted induction) of arrhythmia

Drug testing (before or after ablation at the same session)

Mapping of tachycardia (3D or 2D)

Radiofrequency ablation to destroy and interrupt sites of abnormal electrical activity

Electrophysiology

138

Recording

− Bundle of HIS - 93600

− Intra-atrial - 93602

− Right Ventricular - 93603

− Esophageal recording of atrial electrocardiogram with or without ventricular electrocardiogram - 93615

Pacing

− Intra-atrial - 93610

− Intra-ventricular - 93612

− Esophageal recording of atrial electrocardiogram with pacing – 93616

Edits

− 93600, 93602, 93603 with 93609 zero edits

− (o/w, 93600/02/03 cannot be paid if 93609 is also billed)

Electrophysiology

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139

Induction of arrhythmia by electrical pacing

− 93618

− Includes measures to return heart to normal pace

Edits

− 93618 with 93619/20/21/22, 93640, 93641 zero edits

− 93620 with 93619 zero edits



Electrophysiology

140

Combination Studies

– Right atrial pacing & recording, right ventricle pacing and recording, His Bundle recording w/o induction of arrhythmia – 93619

– Right atrial pacing & recording, right ventricle pacing and recording, His Bundle recording with induction or attempted induction of arrhythmia – 93620

– Two of three levels comprises a “complete study”. MD should describe why all levels NOT done or NOT necessary for that patient.

– Left atrial pacing and recording, can be from a catheter in the coronary sinus or directly in the left atrium, with induction or attempted induction of arrhythmia (add-on code) – 93621

– Left ventricular pacing and recording with induction or attempted induction of arrhythmia (add-on code) – 93622

Electrophysiology: Base and Add-On Codes

141

Drug testing

— Stimulation and pacing after IV drug infusion – 93623

• Drugs infused to induce or suppress an inducible arrhythmia. These include Isuprel, Epinephrine, Atropine, Dobutamine and Procainamide to induce (and Adenosine which is to break or suppress an inducible arrhythmia. This is per the 2013 ACC coding guide, page 243). This is performed during the EP testing and ablation procedures. Rarely may be done with 93624, e.g., if Isuprel is given during a NIPS study as the arrhythmia is not inducible.

— Follow-up study to test effectiveness of ongoing drug therapy or prior ablation – 93624

• Completely separate complete EP study with catheters, may be done as a one-wire study or with a pacemaker using NIPS. Cannot be used with 93620 to describe drug testing after ablation.

Mapping of arrhythmia (CCI edits include 93609 with 93613 zero edits)

— Single plane – 93609

— 3-Dimensional – 93613

Electrophysiology: Add-On Codes

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142

Ablation of Arrhythmia

– AV node (Complete Heart Block) – 93650

• Includes:

– Temporary pacemaker placement

– Localized diagnostic EP study and drug infusions

– Localized mapping of tachycardia

– RF ablation of AV node

– Do not bill 93609, 93613, 93620, 93621, or 93623 for the limited evaluations performed of the AV node when ablation is electively planned and performed.

Electrophysiology: Ablation Codes

143

Code 93653 – Ablation of SVT (single focus of atrial re-entry including cavo-tricuspid isthmus, fast or slow atrioventricular pathway, and/or accessory atrioventricular connection).

— Includes a comprehensive diagnostic study of the right side. If less than a complete study is performed, the MD must document why it was not performed or why it was not necessary.

— If a recent diagnostic study done and patient is brought back for ablation only, add -52 modifier for MD coding (-74 for hospitals).

— Can add left sided diagnostic (93621, 93622), mapping (93609 or 93613), and transseptal approach (93462). (NOT 93620). Code 93623 is to be available starting 4/1/2013 (pending). All these add-on coding issues are related to incomplete parentheticals which are supposed to be corrected shortly.


144

Code 93654 – VT or V ectopy focus ablation (PVC’s). Includes a comprehensive diagnostic study of the right side and left ventricle if necessary.

— If less than a complete study is performed, the MD must document why it was not performed or why it was not necessary.

— If a recent diagnostic study done and patient is brought back for ablation only, add -52 modifier for MD coding (-74 for hospitals).

— Includes mapping. Can add left atrial diagnostic (93621) and transseptal approach (93462). (NOT 93609, 93613, 93620, or 93622). Code 93623 is to be available 4/1/2013 (pending). These add-on coding issues are related to incomplete parentheticals which are supposed to be corrected shortly.


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145

Code 93656 – Atrial fibrillation ablation by pulmonary vein isolation (PVI) technique. Includes complete diagnostic study.

— If less than a complete study is performed, which is possible with Afib treatment, the MD must document why it was not performed or why it was not necessary.

— If recent diagnostic study performed and here for ablation only, add -52 modifier (-74 for hospitals) to the ablation code.

— Includes transseptal approach (93462), comprehensive study (93620) and left atrial evaluation (93621). Can add left ventricular pacing and recording (93622), and mapping (93609 or 93613). Code 93623 is to be available 4/1/2013 (pending). These add-on coding issues are related to incomplete parentheticals which are supposed to be corrected shortly.


146

Code +93655 – Ablation of separate discrete mechanism of arrhythmia distinct from primary mechanism already treated with ablation.

— This can be added on to any of the comprehensive ablation codes 93653, 93654, and 93656.

Code +93657 – Additional ablation of right or left atrium for treatment of continuing atrial fibrillation after pulmonary vein isolation ablation.

— Code 93657 can only be used with code 93656. Code 93657 is used if atrial flutter occurs and is treated after pulmonary vein isolation for atrial fibrillation (this is per the HRS 2013 coding guide).


147

Do not submit codes 93653, 93654, or 93656 together. Use add on codes +93655 or +93657 as appropriate to describe

additional ablations. Use 93657 for treatment of continued atrial fibrillation after PVI or for alation of atrial flutter which occurs after pulmonary vein isolation for atrial fibrillation (93566).

Ablation of Arrhythmia codes 93653-93657 include all single site and comprehensive diagnostic EP codes, except that: — Code 93621 can be used with SVT (non-atrial fibrillation) and

ventricular comprehensive ablation codes 93653 (SVT) and 93654 (VT).

— Code 93622 can be used with right atrial and pulmonary vein isolation (left atrial) comprehensive ablation codes 93653 (SVT) and 93656 (AFIB).

Electrophysiology

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148

Non-invasive programmed stimulation (NIPS) −Via pacemaker for conversion of atrial flutter or

ventricular tachycardia – 93724

−Via pacemaker to assess the efficacy of chronic drug therapy (sotalol) or prior catheter ablation for elimination of inducible ventricular tachycardia – 93624

−Via defibrillator for defibrillator testing with induction and treatment of ventricular tachycardia (not at time of implantation) – 93642

Electrophysiology

149

Rules – Charge separately for drug infusions to induce or suppress an inducible arrhythmia

during an EP study (93623) (starting 4/1/2013…check with NCCI).

– Charge separately for mapping of tachycardia (except for ventricular ablation procedure 93654).

– Charge separately for some coronary sinus catheter work done to evaluate left atrial or left ventricular abnormalities (refer to guidelines).

– Charge separately for elective cardioversion prior to placing catheters for EP study with 92960.

– Do not charge for cardioversion of arrhythmias induced during the EP study.

– Do use combination codes when two of three areas of evaluation are performed, however MD must describe why limited or not necessary, o/w add -52 for MD and -74 for hospital coding (high RA, RV, Bundle of His).

Electrophysiology

150

Rules - Unconditionally Packaged Procedures – Codes 93609, 93613, 93621, 93622, 93623, 93631, 93640, 93641, and 93662

are status indicator N procedures.

– Composite service payment is based on one code Group A (93619 or 93620), Group B (93650) and Group C (93653, 93654, 93656). Only one payment is made for these codes (for hospitals)

Group A Group B

93619 or 93620 - $3,922.31 93650 - $3,922.31

Group C

93653, 93654 or 93656 - $11,145.72

Electrophysiology

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151

CLINICAL HISTORY: 78-year-old woman with history of supra-ventricular tachycardia unresponsive to medications.

PROCEDURE PERFORMED: Catheters are advanced to the high right atrium, bundle of his, right ventricle and coronary sinus for left atrial evaluation.

Right and left atrial, bundle of His and ventricular pacing and recording is then performed. Supra-ventricular tachycardia is induced but only after the administration of intravenous infusion of Isuprel.

After characterization of the tachycardia, 3D mapping is performed. In the right anterior oblique cranial view, there is good separation of the coronary sinus in the AV node region and RF energy is applied. After the fourth RF energy application, junctional beats are noted. The tachycardia is successfully ablated with no supra-ventricular tachycardia inducible at the end on and off Isuprel.

RESULTS: The patient’s baseline rate is 80 beats per minute. AH is 280, HV is 47, VA is 47 milliseconds. SVT is induced and treated.

Electrophysiology Case 18:

152

Electrophysiology Case 18 Codes:

93653 – Comprehensive right sided EP study with ablation of supraventricular tachycardia (SVT)

93621 – Comprehensive EP study with left atrial pacing and recording from coronary sinus or left atrium

93613 – Mapping of tachycardia – 3D

93623 – Programmed stimulation and pacing after intravenous drug infusion

153

DESCRIPTION OF PROCEDURE: Using a standard percutaneous approach, a total of four multipolar electrode catheters are passed into the right femoral vein, and advanced into the high right atrium, region of the bundle of His, right ventricle and coronary sinus. Atrial and ventricular pacing, His bundle recording and left atrial recordings from the coronary sinus are performed. Baseline intervals are measured. Complete EP study on isoproterenol infusion, as well as EP study on epinephrine infusion are performed. No sustained tachycardia can be induced. The procedure is stopped at this point.


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154

93620 – Comprehensive EP study with induction/ attempted induction of arrhythmia

93621 – Comprehensive EP study with left atrial pacing and recording from coronary sinus or left atrium

93623 – Programmed stimulation and pacing after intravenous drug infusion


155

PROCEDURE: Patient with prior diagnostic EP study, here for A-Fib treatment by pulmonary vein isolation technique ablation. Via a right femoral access, two sheaths are placed. ICE catheter is advanced into the right atrium for performance of transseptal procedure. This is followed by advancement of a Brockenbraugh needles and Mullins’ sheaths for double transseptal puncture. 3D mapping is followed by pulmonary vein isolation (A-Fib ablation).


156

93662 – ICE (intra-cardiac echo) 93613 – 3D mapping of tachycardia 93656-52 – Ablation of atrial fibrillation by pulmonary vein

isolation technique (hospitals code as 93656-74)


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157

PROCEDURE: Patient with A-Fib. Pacemaker was turned off at the start of the procedure. Three 8 French sheaths are placed into the right and left femoral vein. ICE catheter is advanced into the right atrium. RA recording is performed, followed by performance of double transseptal puncture. Recording in the LA is performed along with 3D mapping with CT merge prior to performance of pulmonary vein isolation/ablation. Isuprel is infused followed by pacing and recording in the left atrium. After ablation, atrial flutter was noted. A separate line to the mitral valve was necessary to ablate this separate flutter arrhythmia. The catheters are withdrawn and complete diagnostic EP study with right sided recordings (A-H, H-V) and pacing obtained. There is no inducible arrhythmia at the end of the procedure. Pacemaker is turned on and reprogrammed.


158

93656 – Comprehensive EP study with atrial fibrillation ablation by pulmonary vein isolation ablation technique

+93657 – Additional treatment of atrial flutter after pulmonary vein isolation ablation technique for atrial fibrillation treatment

+93623 – Isuprel infusion +93613 – 3D mapping of tachycardia +93662 – ICE (intra-cardiac echo) 93286 x 2 – Peri-procedural pacemaker evaluation before and

after ablation procedure


159

Patient with apparent ventricular tachyarrhythmia. Comprehensive EP study is performed with pacing and recording (high RA, His and RV). Ventricular tachycardia is induced. This is treated with ablation. There appeared to be a second pathway, possibly on the left side. Transseptal puncture is performed and left ventricular diagnostic EP study is performed. 3D mapping of the LV is done. Ablation of separate mechanism left sided VT is performed. Catheters are removed.


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160

93654 – Comprehensive diagnostic EP study with VT ablation, right sided

93462 – Transseptal approach for left-sided evaluation

93655 – Additional ablation of left sided VT, different mechanism than right sided VT (e.g., scar on right side and His bundle issue on left)

** Codes 93620, 93622, and 93613 are bundled.


161

Patient with apparent ventricular tachyarrhythmia. One wire study done with right ventricular pacing. Ventricular tachycardia was induced. Patient was then prepped and a single chamber defibrillator was placed using fluoroscopic guidance. Defibrillation threshold testing was deferred.


162

93612 – Ventricular pacing

93618 – Induction of arrhythmia

33249 – Single chamber defibrillator and lead placement


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163

Transvenous Pacemaker Procedures

164

-FB Modifier Used to denote device provided at no cost to the provider

Used for recall of devices

Used for rebates given for devices

Appended to procedure code for device implantation affects “device-dependent” APCs

Payment reduced by an “offset” amount

Offset amount is % of APC payment attributable to device payment

Offset % varies from 41.88% to 90.44% depending on APC

165

-FC Modifier Used to denote device provided with a manufacturer partial credit

of 50% or more of the cost of a new device

Used for partial credit received for replaced devices

Not used for routine volume rebates given for devices

Appended to procedure code for device implantation affects “device-dependent” APCs

Payment reduced by an “offset” amount

Offset amount is 50% of the amount of the APC payment attributable to the device payment

Offset % varies from 22% to 45% depending on APC

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166

167

168

New Definitions of device types:

― Single Lead – Pacer or ICD with pacing and sensing function in only one chamber of the heart

― Dual Lead – Pacer or ICD with pacing and sensing function in two chambers of the heart

― Multiple Lead: Pacer or ICD with pacing and sensing function in three or more chambers of the heart

― More than one lead may be necessary in a single chamber. Based on # chambers.

― Fluoroscopy is bundled with all Pacer/ICD codes (however 76000 is billable if the only procedure performed is looking at the leads without changes to the leads and not during any procedure billed with codes 33206-33249). Code 71090 deleted in 2012.

― “Dual lead” also refers to right and left ventricular leads only (without RA lead) for generator change codes (use 33228 or 33263)

― Code 33208 requires dual chamber pacemaker generator and dual lead placements in the right atrial and right ventricular chambers of the heart.

― Code 33249 requires ICD generator and single or dual lead placement(s) in the RA/RV.

Pacemaker Procedures

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169

Implantation of new pacemaker generator with lead(s), (no prior devices):

– Insertion of new of permanent pacemaker and lead(s):

• Atrial – 33206 (single generator and one lead in RA)

• Ventricular – 33207 (single generator and one lead in RV)

• Atrial & Ventricular – 33208 (dual generator, 2 leads, one in RA, the other in RV)

• Biventricular – 33225 (add-on code for LV lead inserted at same time as initial pacer insertion or replacement, includes pocket revision)

– Insertion of temporary pacemaker:

• Single chamber – 33210 (use for symptomatic bradycardia and generator exchange in pacer dependent patient, bundled for use at time of AV node ablation, coronary artery and carotid artery interventions)

• Dual chamber - 33211


170

Removal of old generator, removal of lead(s), implantation of new pacemaker generator requiring implantation of new lead(s):

Code for the following components if performed:

― Removal of old pacemaker generator (33233)

― Removal of old pacemaker lead(s):

• by transvenous approach:

Single lead system: 33234

Dual lead system: 33235

• by thoracotomy approach:

Single or dual lead system:33238

― Implantation of new of permanent pacemaker and lead(s),

• Atrial – 33206 (single generator and one lead in RA)

• Ventricular – 33207 (single generator and one lead in RV)

• Atrial & Ventricular – 33208 (dual generator, 2 leads, one in RA, the other in RV)

• Biventricular – 33225 (add-on code for LV lead inserted at same time as pacemaker upgrade, includes pocket revision)


171

Implantation of new pacemaker generator with new lead(s), in a patient with prior pacemaker, leads are not removed:

― Code for the following components if done:

• Removal of old pacemaker generator (33233)

• Do not code for capping of lead(s)

• Implantation of new of permanent pacemaker and lead(s),

Atrial – 33206 (single generator and one lead in RA)

Ventricular – 33207 (single generator and one lead in RV)

Atrial & Ventricular – 33208 (dual generator, 2 leads, one in RA, the other in RV)

• Upgrade from single to dual chamber pacemaker including removal of old generator, testing of existing lead, placement of new generator & lead - 33214

Biventricular – 33225 (add-on code for LV lead inserted at same time as pacemaker upgrade, includes pocket revision)


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172

Removal of old generator with implantation of new pacemaker generator only:

― Use a single code to describe the entire procedure:

• Single lead system – 33227

• Dual lead system – 33228

• Multiple lead system – 33229

― Leads are not impacted in this scenario as they are not removed and are not replaced. These codes only apply to patients with pre-existing systems who only need a generator change (e.g., EOL battery exchange).

― If a lead is capped in an existing dual lead system, only one functioning lead is left in place, the dual lead generator is removed and a single lead generator is placed, recommend 33227. (downgrade of system from dual to single lead).

― If a lead is added to the exchanged generator, code for the removal of old generator (33233) and 33206-33208 as appropriate. If lead(s) is/are removed, also code for the removal with 33234 or 33235.

― Code 33228 applies to biventricular pacemaker without RA lead (leads in 2 chambers).


173

Insertion of new generator in patient with previously placed lead(s):

― Use a single code to describe the entire procedure:

• Generator insertion with existing single lead – 33212

• Generator insertion with existing dual leads – 33213

• Generator insertion with existing multiple leads – 33221

― Leads are not impacted in this scenario as they have been placed at a previous surgery.


174

Insertion of lead(s) only, for pacemaker or defibrillator system − Electrode only (code for the number of electrodes placed)

• Insert one electrode – 33216

• Insert two electrodes – 33217

• Addition of left ventricular lead to existing system – 33224

• Addition of left ventricular lead at time of initial implant – 33225

Do not use code 75860 for coronary sinus venography

Do not code for venoplasty of the coronary sinus

Do not code pocket revision (as in 2012 CPT code description)

• Consider 33217 vs. 33999 for subcutaneous array placed posteriorly along ribs. Discuss with your payer.


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175

Removal of lead(s) only from pacemaker ― Based on single lead vs dual lead transvenous system:

• Single lead system (use for removal of lead(s) based on single chamber/lead system) – 33234

• Dual lead system (use for removal of lead(s) from a dual chamber/lead system) – 33235

― Removal of transvenous leads by thoracotomy: • 33238

― Lead(s) AND epicardial pacemaker removal by thoracotomy • Single lead system: 33236 • Dual lead system: 33237

Do not code for capping of leads. Actual removal of leads can be quite complex and may require laser. If

laser required, MD should consider -22 modifier. These codes are not appropriate with -62 modifier. Removal of Left Ventricular Lead : Bill the same codes as RV, RA lead removals Removal of actively fixated RV “temporary” lead (for infected permanent system): 33234


176

Repair electrode for pacer or ICD (fix a fracture or insulation defect, terminal pin modification, etc), charge for the number of electrodes repaired:

− Repair one lead: 33218

− Repair two leads: 33220

Repositioning of previously implanted electrode

− Atrial or ventricular lead – 33215 (bill twice if two leads repositioned)

− Left ventricular lead – 33226

Open pocket and tighten set screws (not reposition or repair) – 33999

Revision/relocation of pacemaker pocket – 33222

− Done for generator erosion or infection (e.g., subpectoral placement)

“Including removal, insertion and/or replacement of generator”

− Refers to the opening of the pocket, placing the existing generator on the chest, doing your lead work, and placing the existing generator back into the pocket, not a completely new generator (referring to codes 33224 and 33226).


177

Implantable Loop Recorder Placement – 33282

Implantable Loop Recorder Removal – 33284

Codes 93279-93287 for “in-person” evaluations

Do not report codes 93297-93299 at same session as pacer/ICD codes 33206-33249.

93286 x 2 – Turn off and turn on pacemaker with reprogramming for surgery/EP ablation (may be bundled with EP in 2013)

Pacemaker/Loop Recorder Procedures

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178

PROCEDURE: Elective DC cardioversion and implantation of dual-chamber pacemaker. Patient has previously placed epicardial leads from previous cardiac surgery. Patient has atrial flutter.

DESCRIPTION OF PROCEDURE:

She is prepped and draped in the usual manner. Local infiltration with Lidocaine, left infraclavicular incision, and pocket formation. The dual lead pacer generator is attached to the pre-existing leads. The patient’s sensing and pacing thresholds are tested and are adequate. The pacemaker pocket closed. The patient is then cardioverted to a normal sinus rhythm.

Fluoroscopy was used throughout the entire procedure.

Pacemaker Case 24:

179

33213 – Insert dual chamber pacemaker generator to existing leads

92960 – Elective external cardioversion

Pacemaker Case 24 Codes:

180

PROCEDURE: Dual pacemaker pulse generator exchange.

PREPROCEDURE DIAGNOSIS: Complete heart block, pacemaker battery depletion.

PROTOCOL: Via a trans-femoral venous approach, a temporary pacer is placed fluoroscopically with the lead tip in the RV and activated. Then the left chest is prepped and draped in sterile fashion. 1% lidocaine is used for local anesthesia. An incision is made over the pulse generator and dissection carried out to the pseudocapsule. The pseudocapsule is incised and the pulse generator and redundant leads are removed from the pocket. The leads are disconnected from the pulse generator and sensing and pacing thresholds are performed. Impedance is 563 ohms. The patient is pacemaker dependent. A new dual generator is placed and attached to the RV and RA leads. The temporary pacer was removed.

Pacemaker Case 25:

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181

33210 – Temporary pacemaker placement 33228 – Dual lead system generator exchange Temporary pacer is separately coded as the patient was pacer dependent. Old generator removal and new generator placement is included in a single code.


182

DESCRIPTION OF PROCEDURE: Using 1% lidocaine local infiltration, standard percutaneous approach, a total of two multipolar electrode catheters are passed into the right femoral vein, advanced into the high right atrium, region of bundle of His, right ventricle. Atrial recording, ventricular pacing, and then His bundle recording are performed.

HV measures 50 milliseconds. Careful mapping of the AV node, His bundle region is done. Radiofrequency energy is applied. A total of 6 RF energy is applied, and heart block is created, ten seconds after RF energy dose is delivered. Temporary pacemaker is then inserted.

A dual pacemaker from a left sided approach is placed. Fluoroscopy is utilized. After placement the pocket is closed in layers using 2-0 Vicryl in the subcutaneous layer. The skin is closed with staples.

Pacemaker Case 26:

183

93650 – Ablation of AV node 33208 – Insert dual chamber pacemaker Temporary pacer placement is included in the ablation/ permanent pacer placement. Fluoroscopy is bundled.


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184

A. Patient for dual pacer generator exchange for battery end-of-life. At exchange, the atrial lead is checked while two ventricular leads are removed, with placement of a new ventricular lead (using fluoroscopy) and new dual pacer generator.

Pacemaker Case 27:

185

33233 – Removal of old pacer generator

33235 – Removal of two leads from the single chamber of a dual lead system

33207 – Single generator pacer placement

Pacemaker Case 27-A Codes:

186


B. Same patient, but this time one ventricular lead is repaired at time of dual generator exchange, no leads are removed or placed, and fluoroscopy was not utilized.

Pacemaker Case 27-B:

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187

33228 – Dual generator replacement

33218 – Lead repair (based on number of electrodes repaired)

Pacemaker Case 27-B Codes:

188



C. Same patient, but now both leads repaired.

Pacemaker Case 27-C:

189

33228 – Dual generator replacement

33220 – Lead repair (based on number of electrodes repaired)

Pacemaker Case 27-C Codes:

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190




D. Same patient, but the atrial and one ventricular lead are removed and one atrial lead is placed using fluoroscopy. Same generator is re-used.

Pacemaker Case 27-D:

191

33235 – Removal of leads from two chambers

33216 – Placement of one lead (in the atrium)

Pacemaker Case 27-D Codes:

192




D. Same patient, but the atrial and one ventricular lead are removed and one atrial lead is placed using fluoroscopy. Same generator is re-used.

E. Patient with dual chamber, bi-ventricular pacemaker for generator exchange. During exchange, the LV lead was noted to be floating in the RV and required repositioning into the coronary sinus.

Pacemaker Case 27-E:

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193

33229 – Removal of old and replacement with new multiple lead permanent pacemaker generator

33226 – Repositioning of existing LV lead into the coronary sinus

Pacemaker Case 27-E Codes:

194

Transvenous Defibrillator Procedures

195

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197

-Q0 Modifier

Used on initial defibrillator placement code

To identify patients whose data is being submitted to a registry and to document meeting the coverage requirement for devices implanted for primary prevention of sudden cardiac arrest.

198

-Q0 Modifier Diagnoses that are Covered w/o -Q0 Modifier

– 427.1 Ventricular tachycardia

– 427.41 Ventricular fibrillation

– 427.42 Ventricular flutter

– 427.5 Cardiac arrest

– 427.9 Cardiac dysrhythmia, unspecified

– 996.04 Mechanical complication of cardiac device, implant, and graft, due to automatic implantable cardiac defibrillator.

– V53.32 Fitting and adjustment of other device, automatic implantable cardiac defibrillator.

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199

Medical Necessity Physicians must document reason for ICD placements. Possible

exclusions include:

− Ejection Fraction > 35%

− Prior MI less than 40 days ago

− CABG or Percutaneous intervention within last 3 months (currently down to 67 days in reviews)

−Other causes

−DOJ reviews based on data mining for dates of recent MI or coronary intervention and ICD placement

200

Defibrillator generator placement only (when leads are already present; e.g., existing leads from a prior surgery)

– 33240 – Insertion of ICD generator, existing single lead

– 33230 – Insertion of ICD generator, existing dual leads

– 33231 – Insertion of ICD generator, existing multiple leads

Defibrillator Procedures

201

Removal of old ICD generator and placement of new ICD generator (no lead removal or placement)

– 33262 – Removal and replacement of ICD generator, existing single lead system

– 33263 – Removal and replacement of ICD generator, existing dual lead system

– 33264 – Removal and replacement of ICD generator, existing multiple lead system


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202

Replacement

− Use new defibrillator insertion code 33249 for placement or replacement of a lead and generator. This is considered a new system.

− Use 33249 for upgrading from single to dual chamber defibrillator (if a new generator and a new lead are placed) THIS ALSO HAS IMPLICATIONS FOR LEAD RECALL AT TIME OF GENERATOR CHANGE…..CORRECT CODING IS 33249. DUE TO $ <50% OF VALUE OF 33249, SHOULD NOT NEED -FB MODIFIER ON 33249. WILL NEED TO BILL LEAD DEVICE AT $1.00. AWAITING CMS CONFIRMATION>

− When old lead removal and new lead placement along with generator exchange is performed, charge for removal of defibrillator generator (33241), removal of lead(s) by thoracotomy (33243) or by transvenous extraction (33244) as appropriate, and placement of new generator with lead(s) with 33249.

− If old generator and one lead are removed of a dual chamber ICD and a new single chamber generator is placed (no new lead), use code for single chamber generator exchange (33262) and lead removal (33244).


203

Left ventricular lead insertion at the time of defibrillator insertion or replacement – 33225

− Do not use code 75860 for coronary sinus venography

− Do not code for venoplasty of the coronary sinus

− Do not code for pocket revision

EP testing of the defibrillator (separately billable)

− Leads only (at time of implant, rarely done, performed when surgeon places leads via thoracotomy and cardiologist tests leads) – 93640

− Leads and generator (at time of implant, commonly performed) – 93641 (do not use 93642 for this procedure)

− Defibrillator (existing system, leads and generator,

performed at a later date) – 93642


204

Insertion of lead(s) only, for pacemaker or defibrillator system

− Electrode only (code for the # of leads placed, not the generator type)

• One electrode – 33216

• Two electrodes – 33217

• Addition of left ventricular lead to existing system – 33224

• Insertion of epicardial electrode(s); open incision – 33202

• Insertion of epicardial electrode(s); endoscopic approach– 33203

• Use codes 33202/3 with generator insertion only codes (33212, 33213, 33221, 33230, 33231, 33240)

Removal of lead(s) only, defibrillator only

− Single or Dual Electrode(s):

• By thoracotomy – 33243

• By transvenous extraction – 33244

• Do not code for capping of leads. Actual removal of leads can be quite complex and may require laser and -22 modifier for physician billing.


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205

Repair electrode (fix a fracture or insulation defect, terminal pin modification, etc), (code for number of leads repaired)

− 1 lead – 33218

− 2 leads – 33220

− Can use repair codes with removal/replacement of generator codes 33227-33229 and 33262-33264 as appropriate

Repositioning of previously implanted electrode

− Atrial or ventricular lead – 33215

− Left ventricular lead – 33226

Revision/relocation defibrillator pocket – 33223

− Done for generator erosion or infection

Turn off and turn on defibrillator with reprogramming for surgery or EP ablation – 93287 x 2


206

CLINICAL HISTORY: This is an 86 year old gentleman with a history of ventricular tachycardia, syncope and severe ischemic cardiomyopathy. Because of this, ICD implantation is indicated. The patient has a pre-existing single lead pacemaker generator that will be extracted as well as the lead.

PROCEDURE: The left subclavian region is prepped and draped in the usual fashion. The pocket is opened. The old pacemaker and the single ventricular screw-in pacing lead are removed without any difficulty. Contrast is injected to visualize the venous system. A defibrillating lead is then placed at the right ventricular apex. Pacing and sensing thresholds are adequate. A new ICD generator is inserted and the lead is attached to the device. The ICD is tested. VF is induced twice, at 10 and 20 joules.

Defibrillator Case 28:

207

33249 – Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator

93641 – Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement; with testing of single or dual chamber pacing cardioverter-defibrillator pulse generator

33233 – Removal of old pacer generator 33234 – Removal of lead(s) from a single lead pacemaker system

Defibrillator Case 28 Codes:

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208

PROCEDURE: Implantation of dual-chamber biventricular ICD. Coronary sinus venography. Coronary sinus venoplasty.

CLINICAL HISTORY: Symptomatic ventricular tachycardia.

DESCRIPTION OF PROCEDURE: Local anesthesia with lidocaine is followed by a left infraclavicular incision and pocket formation. Cannulation of the left subclavian vein is done with placement of three peel-away sheaths.

Subclavian venography is performed. The cephalic vein, subclavian vein, axillary vein, innominate vein, RA, and RV are visualized. There is tortuosity of the veins. As such, long sheaths are used to place two leads, one each into the RA and RV locations.


209

The coronary sinus is then successfully cannulated with a catheter. Coronary sinus venography documents a small coronary sinus so 4mm balloon venoplasty is performed to stretch the sinus to accept the sheath. The sheath is then advanced into the coronary sinus. The pacing lead is passed through the sheath into the lateral cardiac vein. Pacing and sensing thresholds are adequate. All leads are hooked up. System testing is undertaken.

After adequate anesthesia, VF is induced twice. Defibrillation threshold is greater than 10 joules, less than 15 joules. The pocket is then closed in layers using 2-0 Vicryl. The subcutaneous tissue and skin are closed with staples. Fluoroscopy is used throughout the procedure.

Defibrillator Case 29 (continued):

210


33225 – Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter defibrillator or pacemaker pulse generator (including upgrade to dual chamber system) (List separately in addition to code for primary procedure)



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211

PROCEDURE: AV node ablation, dual chamber pacemaker generator removal, RV lead removal, biventricular defibrillator implantation.

INDICATIONS: 83 year old male presents for an upgrade to a defibrillator with synchronization therapy. He also presents for AV node ablation.

PROTOCOL: 5 French and 8 French sheaths are placed in the right femoral vein. A quadripolar catheter is directed to the right ventricular apex to serve as a temporary pacing wire. The ablation catheter is advanced to the atrioventricular junction and radiofrequency energy is delivered. This results in complete heart block.


212

DEFIBRILLATOR SESSION: An incision is made over the pulse generator and dissection carried out. The pseudocapsule is incised and the dual chamber pulse generator and 2 leads are removed from the pocket. The right ventricular lead is disconnected from the pulse generator and removed with laser assistance. The right atrial lead is left in place. Under fluoroscopic guidance, the left subclavian vein is cannulated and a guidewire and sheath are placed. The new right ventricular defibrillator lead is introduced through the sheath. It is directed to the right ventricular apex.


213

The subclavian vein is again cannulated under fluoroscopic guidance. A steerable quadripolar catheter is used to direct the sheath into the coronary sinus. A balloon tip catheter is placed into the coronary sinus. Venograms are obtained. The left ventricular lead is inserted through the sheath. The lead is then advanced over the guidewire into appropriate position. The new right defibrillating and left ventricular leads and chronic right atrial lead are attached to the defibrillator.

The patient undergoes defibrillation threshold testing. The patient is induced into ventricular fibrillation. Initial cardioversion energy of 17 joules results in restoration of sinus rhythm.


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214

93650 – Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement


33225 – Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (including upgrade to dual chamber system) (List separately in addition to code for primary procedure)


33233 – Removal of permanent pacemaker pulse generator 33235 – Removal of transvenous pacemaker electrode(s); dual lead system


215

PROCEDURE: Patient presents with a dual chamber ICD here for upgrade to a dual chamber bi-ventricular ICD (multi-lead system) for resynchronization therapy. The RV lead was NOT removed or replaced. Defibrillation threshold testing was done at the end of procedure.


216

33264 – Removal of old dual chamber ICD generator with placement of a multi-lead ICD generator (includes removal and placement in a single code, no RA or RV lead placed)

33225 – Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (including upgrade to dual chamber system) (List separately in addition to code for primary procedure)



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217

Code 0281T – Percutaneous left atrial appendage ablation

Codes 0291T and 0292T – Optical coherence tomography (OCT)

Codes 0293T and 0294T – Left atrial pressure monitoring system

Codes 0302T-0307T – Intracardiac ischemia monitoring system (IMD) codes (ok as outpatient)

Code 0318T – TAVR via open trans-apical approach

Codes 0319T-0328T – Subcutaneous defibrillator (SICD) codes

Cardiology New Technology Codes for 2013

HeartPOD

Percutaneous Left Atrial Monitor Insertion

Insertion of left atrial hemodynamic monitor; complete system. Includes the implanted communication module and pressure sensor lead into the left atrium, the transseptal access, any injection of contrast, imaging and radiological S&I: 0293T

Insertion of left atrial hemodynamic monitor; pressure sensor lead at the same time as placement of an ICD generator. Includes injection of contrast, imaging and radiologic S&I: + 0294T

HeartPOD Implantable Sensor Lead(ISL) is placed as part of the LAP (Left Atrial Pressure) Monitoring System

219

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AngelMed® Guardian System, INVESTIGATIONAL Single lead is placed in RV apex used to detect cardiac ischemia (STEMI)

221

Code 0302T – Insertion of a complete system, or removal and replacement of IMD, including both device and electrode, interrogation and programming

Code 0303T – Insertion of electrode only, or removal and replacement of the electrode

Code 0304T – Insertion of the device only, or removal and replacement of the device.

Code 0305T – Programming device evaluation (in person) of IMD, with iterative adjustment, analysis, review and report

Code 0306T – Interrogation device evaluation (in person) of IMD, with analysis, review and report

Code 0307T – Removal (without replacement) of IMD

Cardiology New Technology Codes for 2013 Intracardiac Ischemia Monitoring System (IMD)

Subcutaneous Defibrillator

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223

Subcutaneous defibrillators (SICDs) are for patients who do NOT need pacing capabilities.

Code 0319T – Insertion of a complete system, or removal and replacement of complete SICD, including both device and electrode, interrogation and programming, pocket revision and pocket repositioning if done.

— If existing generator and lead are removed, additionally use codes 0322T and 0324T.

Code 0320T – Insertion of electrode only

Code 0321T – Insertion of the device only (when pre-existing lead is in place

Code 0322T – Removal of SICD generator

Cardiology New Technology Codes for 2013 Subcutaneous Defibrillator (SICD)

224

Code 0323T – Removal and replacement of SICD generator

Code 0324T – Removal of SICD electrode

Code 0325T – Repositioning of SICD electrode and/or generator

Code 0326T – EP evaluation (includes defibrillation threshold evaluation, induction of arrhythmia, testing sensing, programming or reprogramming of parameters

Code 0327T – Interrogation device evaluation (in person) with analysis, review and report, including connection, recording and disconnection per patient encounter

Code 0328T – Programming device evaluation (in person) with iterative adjustment of SICD to test function of device and select optimal permanent programmed values with analysis

Cardiology New Technology Codes for 2013 Subcutaneous Defibrillator (SICD)

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Copyright © 2013 ZHealth Publishing

David Zielske, MD,

CIRCC, CPC-H, CCC, CCS, RCC

CPT © 2012 American Medical Association

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