Changes Coming for 2013 CPT Codes

The 2013 CPT codes have been finalized; brace for an overhaul in the way you report ablation procedures effective January 1st. Gone are the codes we’ve used for eons to report all SVT and VT ablations — in their place are monolithic beasts which must be conquered to secure full reimbursement for future ablations.

Code 93651 is currently used to report all supraventricular tachycardia ablations. This service is typically reported in addition to a diagnostic EP study and mapping of some sort. Left atrial pacing and recording (93621), Isuprel infusion (93623), and intracardiac echo (93662) are occasionally reported at the time of an SVT ablation.

The biggest problem with code 93651 is that it encompasses all forms of SVT ablation without providing additional credit for complex ablations like atrial fibrillation ablation, arrhythmias originating from multiple focal points, or procedures requiring the interruption of multiple pathways.

CPT 2013 partially fixes this problem by including five new codes that can be used to report ablation procedures in a way that permits more precise reporting of complex procedures. However, the new codes include a lengthy “honey do” list of procedural components that must be performed and documented in order to secure whatever premium payers decide to grant ablation procedures. If we fail to hit every checkbox on the list, it will be necessary to attach the reduced service modifier (52) to the new ablation codes and risk substantial payment reduction.

From the mile-high view, you’ll see four codes available to report basic ablation procedures in 2013. The AV node ablation procedure code (93650) is the same as it ever was — no changes here. However, code 93656 stands out as the new atrial fibrillation ablation code. This is an “all in one” code intended to encompass the full scope of the procedure — kind of. But to report it, you must perform and document each of the listed procedural components. Here they are:

• Multiple transseptal catheterizations
• Induction or attempted induction of an arrhythmia
• Right and left atrial pacing (when possible)
• Right and left atrial recording (when possible)
• Right ventricular pacing
• Right ventricular recording
• His bundle recording
• Pulmonary vein isolation

If any of these procedural components are missing from your documentation, it will be necessary to report 93656-52 — the dreaded 52 modifier forces the claim to be manually priced by payers (long payment delay and reduced compensation). 

On the bright side, code 93656 does not always have to be reported alone. CPT 2013 introduces an add-on service code that can be used when additional ablations are required after the pulmonary vein isolation portion of the procedure. Code 93657 is used to report “additional linear or focal intracardiac catheter ablation of left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation.” Better yet, CPT 2013 does not restrict us from reporting this add-on code just one time. Therefore, you could rack up some serious RVUs by creating more complete ablative lesion sets during the initial procedure. 

Code 93655 can also be reported after an AF ablation for cases in which the AF ablation unmasks another SVT. This code is to be used for “ablation of discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism.” Like 93657, code 93655 is an “add-on” code that can be reported multiple times.

While the pulmonary vein isolation procedure code does not need to be reported by itself, its definition establishes that it includes transseptal catheterization as well as atrial pacing and recording. Because of this, it would not be appropriate to report these services in addition to code 93656: LA pacing and recording (93621) and transseptal catheterization (93642).

Other than pulmonary vein isolation, all SVT ablations are still considered equal as far as the basic procedure is concerned. AVNRT, WPW, and atrial flutter ablations are lumped together under code 93653. Similar to the code for pulmonary vein isolation, code 93653 has a “honey do” list of procedural components that must be performed in addition to the ablation procedure. The ablation itself is defined as “ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavotricuspid isthmus or other single atrial focus or source of atrial re-entry.” Here is the “honey do” list:

• Induction or attempted induction of an arrhythmia

• Right atrial pacing

• Right atrial recording

• Right ventricular pacing

• Right ventricular recording

• His recording 

The 52 modifier should be applied to 93653 when less than the full list of procedural components is performed and documented. Also similar to the AF ablation procedure coding, the add-on code 93655 can be reported in addition to this SVT ablation code for additional lesions created after the basic ablation procedure is complete.

The other new basic ablation code CPT 2013 introduces is 93654. This is the new package code we’ll use to report ventricular tachycardia ablations. In addition to each of the procedural components that are included in the new SVT ablation code, this VT ablation code also includes 3D mapping (93613) when performed and left ventricular pacing and recording (93622) when performed. Therefore, it is not appropriate to report these services in addition to the VT ablation code.

This brings us to all of the other services that are not included in the new code definitions. It is still appropriate to report Isuprel infusion (93623), 2D mapping (93609), intracardiac echo (93662), and arterial line placement (36620) when performed in addition to each of the new ablation codes. Three-dimensional mapping (93613) and left ventricular pacing and recording (93622) can also be reported with each of the new ablation codes except 93654 (the new VT ablation code). Left atrial pacing and recording (93622) and transseptal catheterization (93642) can be reported with all but the pulmonary vein isolation procedure code.

Only one pacemaker/defibrillator code was tampered with in CPT 2013; it is the add-on code (33225) we use to report the addition of a left ventricular lead to a new pacemaker or defibrillator generator. 

The first parenthetical note listed under code 33225 establishes which base procedures it can be “added on” to. Removed from the list is 33222 (pacemaker pocket revision) and added are codes 33228, 33229, 33263, and 33264. These are the generator change out codes for dual chamber pacemakers, multiple chamber pacemakers, dual chamber defibrillators, and multiple chamber defibrillators, respectively. The absence of codes 33227 and 33262 (the single chamber generator change out codes for pacemakers and defibrillators) is noted. 

Codes 33227 and 33262 are not appropriate base codes for the LV lead add-on procedure, because earlier this year the American Medical Association provided a major clarification on how to code for generator change outs that involve the addition of a left ventricular lead. In short, we were instructed to report the LV lead add-on code in addition to the generator change out code that reflects the type of system we are upgrading to (not the one we started with). If a patient has a single chamber pacemaker upgraded to a system with an RA and RV lead, we should report it as a dual chamber generator change out (33228) and the LV lead add-on code (33225). Because of this clarification, the codes for single chamber generator change out would never be appropriate — we would not put in an LV lead to upgrade to a single chamber system.

The second alteration to code 33225 comes in the form of a new parenthetical note that reads as follows: “Use 33225 in conjunction with 33222 only with pacemaker pulse generator pocket relocation and with 33223 only with pacing Cardioverter-defibrillator [ICD] pocket relocation.” You’ll also notice that the words “and pocket revision” were removed from the code definition. These related changes establish that we should report pocket revision when a pocket is relocated at the time of adding an LV lead to a new generator. 

Perhaps harder to keep up with than the new codes next year will be keeping up to date with the soon to be overhauled indications for pacemakers and defibrillators. A lot of attention has been brought to the deficiencies in the current coverage indications, and all signs point to the fact that the policies are soon to be updated. Expanded indications for dual chamber pacemakers and clarification regarding the stipulations of primary prevention defibrillator implants are eminent. With all the attention afforded left ventricular leads this year, a policy for biventricular pacing is probably not too far into the future. 

It will be critical to stay on top of these developments as they happen, since Medicare Administrative Contractors and the Department of Justice are aggressively auditing to identify and prosecute derivations from the embattled and outdated National Coverage Determinations.