Reimbursement
Electrophysiology Billing Primer
Unique Billing Codes for Ablation Procedures
Ablation Services
The four basic types of ablation procedures (SVT, PVI, VT, & AVN) have unique billing codes. When these codes are reported, they generate revenue for the ablation and for additional services considered integral to the procedure. For example, a complete* EP study is considered to be an integral component of SVT, PVI, & VT ablations. Other bundled services include:
- LA pace & record and transseptal puncture are components of PVI
- Mapping and LV pace & record are components of VT ablation
- EP studies and mapping should not be reported with AVN ablation
*CPT™ defines a complete EP study as one including RA pacing, RV pacing, RA recording, His bundle recording, RV recording, and attempted induction of arrhythmia. However, CPT instructs that “When performance of one or more components is not possible or indicated, document the reason for not performing.” As such, it is not necessary to perform all the components of comprehensive EP study in order to report the ablation code. However, make sure to document something like, “Any components of an EP study not documented above were not indicated.”
| SVT: 93653 ($877, 14.75 wRVU) - Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording (when necessary), and His bundle recording (when necessary) with intracardiac catheter ablation of arrhythmogenic focus; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry |
| PVI: 93656 ($1,177, 19.77 wRVUs) - Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia including left or right atrial pacing/recording when necessary, right ventricular pacing/recording when necessary, and His bundle recording when necessary with intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation |
| VT: 93654 - ($1,174, 19.75 wRVUs) - Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording (when necessary), and His bundle recording (when necessary) with intracardiac catheter ablation of arrhythmogenic focus; with treatment of ventricular tachycardia or focus of ventricular ectopy including intracardiac electrophysiologic 3D mapping, when performed, and left ventricular pacing and recording, when performed |
| AVN: 93650 ($620, 10.24 wRVUs) - Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement |
Separately Reportable Services
The following services may be reported in addition to the applicable ablation service when indicated (exceptions in parentheses).
- 93621-26 - LA pace & record (not with PVI)
- 93622-26 - LV pace & record (not with VT)
- 93623-26 - Induce after infusion (must be diagnostic, not confirmatory)
- 93609-26 - Catheter/2D mapping (not with VT)
- 93613 - 3D mapping (not with VT)
- 93462 - Transseptal puncture (not with PVI)
- 93662-26 - Intracardiac echo
- 93286-26/93287-26 Peri-procedure device reprogramming (only with SVT & AVN)
- 99152 - Moderate sedation (10+ minutes and a dedicated observer documented)
| 93621-26 ($123, 2.1 wRVUs) - Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separately in addition to code for primary procedure) |
| 93622-26 ($180, 3.1 wRVUs) - Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left ventricular pacing and recording (List separately in addition to code for primary procedure) |
| 93623-26 ($166, 2.85 wRVUs) - Programmed stimulation and pacing after intravenous drug infusion (List separately in addition to code for primary procedure) |
| 93609-26 ($291, 4.99 wRVUs) - Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary procedure) |
| 93613 ($311, 5.23 wRVUs) - Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure) |
| 93462 ($220, 3.73 wRVUs) - Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (List separately in addition to code for primary procedure) |
| 93662-26 ($147, 2.8 wRVUs) - Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation (List separately in addition to code for primary procedure) |
| 93286-26 ($16, .3 wRVUs) - Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure, or test with analysis, review and report by a physician or other qualified health care professional; single, dual, or multiple lead pacemaker system, or leadless pacemaker system |
| 93287-26 ($24, .45 wRVUs) - Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure, or test with analysis, review and report by a physician or other qualified health care professional; single, dual, or multiple lead implantable defibrillator system |
| 99152 ($13, .25 wRVUs) - Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older |
Additional Ablations
Two “add-on” services deserve special attention. These services entail creating additional ablations to treat arrhythmias that persist after completion of the primary ablation (PVI, SVT, VT). The “add-on” nature of these codes requires them to be reported in addition to a primary ablation service.
- Additional AF ablation after PVI (93657): This service entails the creation of linear or focal ablations to treat AF that remains after PVI is complete. When applicable, this code may be reported two times. This add-on service may only be reported with PVI.
- Ablation of a “discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism” (93655). This service is the same thing as the first add-on service except it is applicable to non-AF ablations. This add-on service may be reported with SVT, VT, and PVI. For example, it would be reportable with PVI in cases in which the patient converts from atrial fibrillation to atrial flutter after PVI. It may be reported up to two times per case.
Multiple primary ablation procedure codes (SVT, VT, PVI) cannot be reported during the same procedure. Use these add-on services to report ablations performed in addition to the most extensive primary ablation procedure performed.
| 93655 ($447, 7.5 wRVUs) - Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia (List separately in addition to code for primary procedure) |
| 93657 ($447, 7.5 wRVUs) - Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List separately in addition to code for primary procedure) |
Redo PVI
When redo atrial fibrillation ablations are performed, they may be reported the same way as the de novo PVI or as an SVT ablation. The deciding factor is whether or not the procedure included re-isolating the pulmonary veins. When the pulmonary veins are re-isolated, the procedure should be reported the same way as the de novo PVI. When only non-pulmonary vein sites are targeted, the procedure should be reported as an SVT ablation plus intra-cardiac echo, transseptal puncture, mapping, and LA pace and record, when documented. This is because the definition of code 93656 (PVI) specifies that it is only applicable when the pulmonary veins are isolated.
Periprocedural reprogramming
When an implanted pacemaker or defibrillator is reprogrammed before an SVT or AVN ablation procedure, it is appropriate to report code 93286-26 for pacemakers and 93287-26 for defibrillators. These same codes are used to report reprogramming after the procedure. However, the repeat procedure modifier (76) needs to be attached to the second code.
Diagnostic Studies
Diagnostic procedures that do not involve ablations may be reported with one of two codes. Each of the codes includes a comprehensive EP study (RA pace, RV pace, RA record, His bundle record, and RV record.) The difference between the two codes is whether or not attempts were made to induce an arrhythmia. When attempts are made, code 93620-26 is appropriate. When there are no attempts to induce, code 93619-26 should be reported.
Unlike ablation procedures, CPT does not establish that it is appropriate to report the comprehensive EP study codes when portions of the study were not performed and documented. Therefore, diagnostic EP studies that do not include all components of the comprehensive EP study definition should be reported with the 52 modifier attached. This modifier indicates that less than the full definition of the code was provided. It is defined as “reduced service.”
These comprehensive diagnostic EP studies may not be billed in addition to the ablation codes. For SVT, PVI, and VT ablation, a comprehensive EP study is included in the code descriptions.
| 93619-26 ($409, 7.06 wRVUs) - Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted induction of arrhythmia |
| 93620-26 ($655, 11.32 wRVUs) - Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording |
Documentation Pointers
Accurate documentation is needed to secure accurate reimbursement and to minimize regulatory exposure. Keeping the following principals in mind when documenting procedures should help:
- LA pacing AND recording need to be documented to bill for LA pace & record.
- Document the diagnostic nature of induce after infusion. When it is performed to confirm the adequacy of an ablation, it should not be reported.
- Make sure to create structured documentation to support billing add-on ablations. Ideally, the note would describe completion of the primary ablation, establish that an arrhythmia was present after the primary ablation, and that that arrhythmia was the target of the add-on ablation.
- Moderate sedation requires “the presence of an independent trained observer.” Make sure to document this person’s presence and establish that moderate sedation was administered for at least ten minutes.
- Since 3D mapping pays more than 2D mapping, make sure to document that “3D mapping” was performed, when indicated.
Final Notes
- With the exception of the add-on ablation codes (93655 & 93657) and the periprocedural device reprogramming codes (93286-26 & 93287-26) the codes referenced in this guide may only be reported once per procedure. Multiple transseptal punctures, repeat diagnostic studies, repeat infusion and induction, and extensive mapping are all reported with single CPT codes.
- Cardioversion is not separately reportable.
- LA pace and record is only billable with a comprehensive EP study, SVT ablation, or VT ablation.
- LV pace and record is only billable with a comprehensive EP study, SVT ablation, or PVI.
- Pulmonary venography is not separately reportable.
- The 26 modifier is used on certain CPT codes to reflect that we are reporting the professional component of the code.
- Dollar amounts and work RVUs (wRVUs) in this guide are from Medicare’s 2020 national Physician Fee Schedule.
Updated: July 29, 2020
DISCLAIMER
This information is presented for the purpose of illustration only and does not constitute legal or reimbursement advice. Acutus Medical encourages providers to submit appropriate and accurate claims for services rendered. It is the provider’s responsibility to determine medical necessity, the proper methods and locations for delivery of services, and to submit appropriate codes, charges, and modifiers for services rendered.
