A PRODUCT, NEWS AND CLINICAL UPDATE FOR THE ELECTROPHYSIOLOGY PROFESSIONAL MARCH 2010

LLC,

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St. Jude Medical AnnouncesIRASE AF Clinical Trial toEvaluate Cardiac AblationCatheter System forTreatment of AF

St. Jude Medical, Inc.announced it has received anInvestigational Device Exemption(IDE) from the U.S. Food andDrug Administration to beginenrollment in the IRASE AF(IRrigated Ablation SystemEvaluation for AF) trial.

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Sorin Group AnnouncesMarket Release and FirstImplant of Next-GenerationCardiac ResynchronizationTherapy Defibrillator

Sorin Group announced U.S.FDA approval and first implantof its next-generation of cardiacresynchronization therapy defib-rillator (CRT-D), Paradym™

CRT Model 8750.

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Cambridge HeartCompletes Development ofNew MTWA Module

Cambridge Heart, Inc.announced that the companyhas completed the developmentphase of its Microvolt T-waveAlternans (MTWA) OEMModule, and has submitted a510(k) application for regulatoryapproval with the U.S. Food andDrug Administration.

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Our lab is humbly equipped. There is a latemodel mono-plane fluoroscopy unit, a singularthree-dimensional mapping system, an intrac-ardiac ultrasound (ICE) device and an irrigat-ed ablation system. A robot, MRI and multiple3D mapping systems are notably absent.Enough equipment is available to achieve suc-cess, but not so much to allow dust to settle.

So what could this non-academicThoreau-like setting offer to the cohort ofEP Lab Digest readers? An attempt, not cer-tainly comprehensive, and not likely univer-sally agreed upon, to outline some observa-tions, theorems and lessons learned over theyears. Presented herein are notions — somespecific and others more general — that

hopefully will help achieve success in theEP laboratory.

Theorem number one: Strive for flex-ibility of the mind to learn newthings.

An electrophysiologist must be a lifelonglearner. Consider for example, upon finishingtraining in the 1990s, there was no formalteaching on the transseptal puncture, and CRTdevices were yet to be imagined. In fact, whenfirst asked of the possibility that a left ventric-ular lead could benefit congestive heart failure,I was dismissive and unimaginative.

Fifteen years of donning a lead apron has taught me manylessons. A very wise friend once told me success in anyendeavor really involves mastering the obvious. This is clearly

the case in practicing medicine and more specifically, achievingfavorable results in the electrophysiology lab.

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See our Spotlight Interview on Florida Hospital Zephyrhills.See our Spotlight Interview on Florida Hospital Zephyrhills.

#10: Be Aware of Your Post-Op Billing OpportunitiesReimbursement for pacemaker and defibrillator surgeries

includes routine surgical recovery services provided in the 90-daypost-operative period. This is most commonly limited to dis-charge following the procedure and an incision site check short-ly after discharge.

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Top Ten List: Things Electrophysiologistsand Cardiologists Can Do to Increase ProfitabilityJim Collins, Certified Cardiology Coder (CCC), CPC, CHCCPresident, CardiologyCoder.Com, Inc.

There is a lot of low-hanging fruit inmost cardiology and electrophysiologypractices. Following are the top ten

areas in which you can increase the profitabilityof your practice.

Electrophysiology in the “Real” WorldJohn Mandrola, MD Louisville Cardiology, PSC Louisville, KY

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However, Medicare policy specifiesthat “Treatment for the underlying condi-tion or an added course of treatmentwhich is not part of normal recovery fromsurgery” and “Visits unrelated to the diag-nosis for which the surgical procedure isperformed” are separately reimbursable.Medicare requires that we attach the 24modifier to these evaluation and manage-ment services to confirm that they are notroutine post-operative care.

Diagnostic tests, like pacemaker ordefibrillator checks, performed during the90-day post-operative period should alsobe separately reported. Many physicianswait for 90 days before bringing patientsinto the office to evaluate and optimizedevice settings; this wait period is not nec-essary. An alternative approach is to per-form this initial post operative devicecheck at the same time as the incision sitecheck. While no reimbursement will beprovided for the incision site check, thepractice will be compensated for thedevice check.

#9: Use Mid-Level ProvidersEffectively

Medicare’s recent elimination of reim-bursement for consultative servicesremoves the most problematic restrictionassociated with mid-level billing. Now,mid-level providers can render and dictateall consultative, admission, follow-up, anddischarge notes for their supervisingphysician in the hospital setting. As long asthe physician personally evaluates thepatient face-to-face on the same day anddocuments his/her service, the shared visitcan be reported by the physician and paidat 100% of the physician fee schedule.

Mid-level providers can provide follow-up visits in the office setting and thesupervising physician can personally billfor these services as long as Medicare’s“incident-to” rules are met. SinceMedicare has increased reimbursementfor follow-up office visits, we have anincentive to see patients in follow upmore frequently. Having mid-levelproviders see patients back at six-, eight,or ten-month intervals generates morerevenue than personally seeing thepatient at annual intervals.

Mid-level providers can also manageyour device clinics. This will generatemore revenue than if a device companyrepresentative runs the clinic, becauseMedicare has specified that the profession-al component modifier (26) must beappended to any device clinic services pro-vided by a device company representative;

this reduces reimbursement by $20-$31per device check.

#8: Understand the Basics ofElectrophysiology Coding

The American Medical Association’sCurrent Procedural Terminology (CPT) isan expansive set of five-digit codes thatmust be used to report professional servic-es to all payers. Electrophysiology (EP)studies are typically reported with CPTcode 93620, which is defined as“Comprehensive electrophysiologic evalu-ation including insertion and repositioningof multiple electrode catheters with induc-tion or attempted induction of arrhythmia;with right atrial pacing and recording, rightventricular pacing and recording, His bun-dle recording.” However, code 93620should only be assigned if the EP reportdefinitively establishes that each of the sixsub-components of a comprehensive EPstudy was performed: atrial pacing, atrialrecording, ventricular pacing, ventricularrecording, His bundle recording, andattempted arrhythmia induction.

According to the National CorrectCoding Initiative Policy Manual forMedicare Services, “Physicians must avoidupcoding. A HCPCS/CPT code may bereported only if all services described bythat code have been performed.” CPTcontains a second “package” code for EPstudies, 93619, which includes each of thecomponents described by code 93620 withthe exception of attempted arrhythmiainduction. Code 93619 is appropriate forstudies performed on patients who havepersistent arrhythmias that do not requireinduction. CPT also contains six “compo-nent” codes, a sub-set of which should beassigned when the EP report does not sup-port either of the two package codes:93610 (atrial pacing), 93602 (atrial record-ing), 93612 (ventricular pacing), 93603(ventricular recording), 93600 (His bundlerecording), and 93618 (attempted arrhyth-mia induction). If atrial pacing and arrhyth-mia induction is not performed becausethe patient is in atrial fibrillation, it wouldbe necessary to report the sub-set of com-ponent codes that accurately reflects thework performed: 93602 (atrial recording),93612 (ventricular pacing), 93603 (ventric-ular recording), and 93600 (His bundlerecording). Reporting code 93620 wouldbe inappropriate since one third of its def-inition was not performed.

EP studies that also include assessmentof the left atrium and/or ventricle will fre-quently support code 93621 (left atrial pac-ing and recording) or 93622 (left ventricu-lar pacing and recording). However, sincethe code definitions specify that pacing andrecording was performed, the reduced

services modifier (52) should be attachedif the report does not definitively estab-lish that both pacing and recording wereperformed.

Additional CPT codes are available toreport the work associated with standardcatheter mapping (93609), three-dimen-sional mapping (93613), induction attemptsafter drug infusion (93623), and intracar-diac echo (93662). Failure to properlyreport these services can shave hundreds ofdollars from your reimbursement. Althoughablation techniques have greatly evolved inrecent years, the CPT code structure forthese procedures has remained stagnant.Just three codes are available to report abla-tive procedures: 93650 (AV node ablation),93651 (SVT ablation), and 93652 (VTablation). Therefore, the reimbursementyou receive for an atrial fibrillation ablationis the same as you receive for a standardatrial flutter ablation. Fortunately, physi-cians are credited (by the AMA/SpecialtySociety Relative Value Scale UpdateCommittee [RUC]) with seven hours andforty-five minutes of pre-, intra-, and post-op time for every SVT ablation. Because ofthis, there is an incentive to minimize thenumber of lengthy atrial fibrillation casesyou perform.

Make sure to not report code 93527(Combined right heart catheterization andtransseptal left heart catheterization throughintact septum [with or without retrogradeleft heart catheterization]) for the transsep-tal puncture performed to facilitate someleft-sided procedures. The introductory textto the EP section of the CPT bookinstructs that “Intracardiac electrophysio-logic studies (EPS) are an invasive diagnos-tic medical procedure which include theinsertion and repositioning of electrodecatheters...catheter insertion and temporarypacemaker codes are not additionallyreported.” In addition to this clear guidancefrom CPT, the patient may not require adiagnostic heart cath, the physician may notbe credentialed to perform diagnostic heartcaths, and reports rarely (if ever) contain thedata required to support the performance of

a diagnostic heart cath: right and left ven-tricular systolic and end-diastolic pressures,right atrial pressure, pulmonary artery pres-sure, pulmonary artery wedge-pressure,transvalvular mean, peak pressure gradients,valve area determinations, and a determina-tion of cardiac output.

#7: Understand the Basics ofPacemaker and DefibrillatorCoding

Initial implants of pacemakers are typi-cally reported with just two codes: 71090is used to report fluoroscopic imaging, andthe appropriate device system implantcode (33206, 33207, or 33208) is used toreport the surgical portion of the proce-dure. Single-chamber atrial systemimplants should be reported with code33206, single-chamber ventricular systemimplants should be reported with 33207,and dual-chamber system implants shouldbe reported with 33208.

When coded correctly, you will receivemore money for a pacemaker generatorchange out than you do for the implanta-tion of a single-chamber system and only4% less than you would receive forimplanting a dual-chamber system. Whileone oddball code is available to report theskin-to-skin surgical work associated withupgrading from a single-chamber pace-maker to a dual-chamber pacemaker(33214), all other change-out proceduresmust be reported with a collection of CPTcodes that accurately describes the hard-ware components that were explanted andimplanted.

Pacemaker generator extraction is sep-arately reported with code 33233, leadextraction from a single-chamber device isreported with 33234, and lead extractionfrom a dual-chamber device is reportedwith code 33235. Lead extraction is notdifferentiated by the approach used(manual traction vs. laser), by the numberof leads extracted, or by the amount of timethe leads were in service.

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See TOP TEN LIST page 12

About the author:

Jim Collins, CCC, CPC, CHCC is thePresident of CardiologyCoder.Com, Inc. He hasbeen dedicated to physician practice compli-ance and revenue enhancement for seventeenyears: in a consultative capacity, as aCompliance Analyst at The Care Group inIndianapolis, and as the Compliance Officer ofMid Carolina Cardiology in Charlotte, NC. Inaddition to writing a monthly newsletter, Jimconducts physician and staff training, provideschart auditing, and offers billing services inconjunction with affiliated billing companies.

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For the implantation portion of change-out procedures, we must only assign theCPT code(s) that reflect the hardware com-ponent(s) personally implanted. If only agenerator is implanted, report 33212 (singlechamber) or 33213 (dual chamber). If onlyleads are implanted, report 33216 (one lead)or 33217 (two leads). If a generator and atleast one right-sided lead are implanted, it isnecessary to report a system implant code(33206, 33207, or 33208) rather than thecomponent codes, and the system implantcode we use must accurately reflect thehardware that was personally implanted.

For example, if a patient has a dual-chamber pacemaker that requires generatorchange out and a new right atrial lead, it isnecessary to report the codes that reflectwhich hardware was extracted (generator –33233 and right atrial electrode – 33235)and to assign the system implant code thataccurately describes the components per-sonally implanted (single chamber atrialsystem – 33206). Even though the patientwill be discharged with a dual-chambersystem, the fact that a chronic right ventric-ular lead was used prevents us from report-ing the implantation of a dual-chambersystem (33208). Make sure to also reportfluoroscopic guidance (71090) for this caseand any other change-out procedures inwhich you use fluoroscopy (including gen-erator change outs).

Coding for defibrillator procedures isslightly less intricate than coding for pace-maker procedures. Only one systemimplant code (33249) is available; it shouldbe reported for single- and dual-chamberdefibrillator system implants. Just makesure to attach the Q0 (Q-Zero) modifierto all primary prevention implants alongwith a diagnosis code that is in line withthe appropriate primary prevention

indication(s), such as: 428.22 (Chronic sys-tolic heart failure), 412 (Old myocardialinfarction), or 425.4 (Other primary car-diomyopathies). Fluoroscopy (71090) anddefibrillation threshold testing (93641)should be reported in addition to theimplant code when performed.

Defibrillator change out coding is alsomore streamlined than it is for pacemakerchange outs. Whenever you remove adefibrillator generator, make sure to reportcode 33241; when you remove any elec-trodes, report 33244. If you implant just agenerator, report 33240, and if you onlyimplant electrodes, report 33216 (one elec-trode) or 33217 (two electrodes). If youimplant a generator and at least one lead onthe right side of the heart, it is appropriateto report the only available system implantcode (33249). It is also appropriate toreport fluoroscopy (71090) and defibrilla-tion threshold testing (93641) when per-formed at the time of a change out.

Some coding conventions apply equallyto pacemaker and defibrillator services.Lead repositioning (33215) is separatelyreported whenever this service is per-formed outside of the initial implant oper-ative session. Left ventricular lead implantshould be reported with code 33225 whenan LV lead is implanted at the same time asa new generator, or with code 33224 whenan LV lead is added to a previouslyimplanted generator. LV lead repositioningshould be reported with code 33226 whenthis service is performed outside of the ini-tial implant operative session.

Pocket revision (33222 vs. 33223) isgenerally only billable when a chronic gen-erator is repositioned or when upgradingfrom a pacemaker to a defibrillator. It isnecessary to attach the separate proceduremodifier (59) to code 33223 when report-ing pocket revision during a procedureinvolving upgrading from a pacemaker to adefibrillator. This modifier establishes that a

true pocket revision was performed ratherthan simply opening the pocket to explantthe chronic pacemaker generator.

#6: Audit Yourself BeforeMedicare Does

The government is investing one and ahalf billion dollars this year to audit andprosecute healthcare fraud. They have alsoimplemented a nationwide RecoveryAudit Contractor program, which incen-tivizes private contractors to identify inap-propriate billing. Fraud and abuse regula-tions provide for penalties in excess of$10,000 per incident and the governmentdoes not need to prove fraudulent intent;they just need to show that the provideracted in deliberate ignorance or recklessdisregard of the applicable rules. Therefore,it is beneficial to create a paper trail thatillustrates your efforts to comply with cod-ing and documentation guidelines.

A representative sample of ten proce-dural services and ten visits for each doc-tor is typically sufficient. The sampleshould include a mix of EP studies, abla-tive procedures, device implants, genera-tor change outs, consults, admissions, andfollow-up visits. In addition to creatingproof of your efforts to comply with theapplicable rules, annual billing audits fre-quently identify underbilling and uncap-tured charges. It is not uncommon toidentify $40,000-$50,000 in lost revenue(per physician/per year) at the conclusionof the initial audit.

#5: Stay Familiar with CoveragePolicies

Uncertainty regarding which conditionsjustify each of the procedures you performhas a negative impact on profitability. Thiswill cause rendered services to be deniedfor a lack of medical necessity, and it willprevent you from performing other servic-es that would be compensated. The mostcommonly overlooked indication for pace-maker implantation is chronotropic incom-petence; a class I indication. I’m also sur-prised by how many referring physiciansand implanters still believe that they mustwait through nine months of medical ther-apy after a patient is diagnosed with non-ischemic dilated cardiomyopathy beforeoffering a defibrillator; as long as thepatient is enrolled in the ACC data registry(a requirement for all primary preventionimplants for Medicare patients), we onlyneed to wait through a three-month med-ical therapy period.

As coverage policies are a moving target,it would be beneficial to periodically visitMedicare’s web site where these coveragepolicies are maintained: www.cms.hhs.gov/mcd/search.asp?clickon=search

#4: Embrace Remote MonitoringRemote monitoring of pacemakers and

defibrillators is administratively convenient,it facilitates great patient care, and it isfinancially lucrative. The optimal way toreport remote monitoring is to designatefour billing dates on your calendar thatapply practice wide. The date of service foreach 90-day monitoring period is the lastday of the period. Within each of the 90-day periods you must perform at least oneremote interrogation. For newly enrolledpatients, make sure that the patient wasenrolled in your remote monitoring pro-gram for at least 30 days prior to includingthem in the practice wide, 90-day billingbatch. If newly enrolled patients are moni-tored for more than 30 days but less than 90days, indicate the number of days that thepatient was enrolled in remote monitoringin the comment section of your claim.

Keep in mind that remote monitoringprograms can typically run reports detailingevery patient that is being monitored andwhen the most recent interrogation wasperformed. Integrating these reports intoyour charge capture efforts will eliminatethe need to keep track of remote monitor-ing interrogations in your practice manage-ment/billing system.

Also keep in mind that the timing andfrequency at which you see patients in theoffice for threshold and sensitivity evalua-tion does not impact your ability to bill forfour 90-day monitoring periods for eachpatient, every year. While national frequen-cy limitations have not yet been publishedfor the new programming evaluationcodes, most electrophysiologists that I’veinterviewed agree that it is medically nec-essary to conduct threshold testing at six-month intervals for patients who are beingremotely monitored.

#3: Thrive on Heart FailureHeart failure is the number one cause of

admission for the Medicare population. Assuch, Medicare is incentivizing the effectivemanagement of this epidemic. Medicarecurrently compensates about $50/patient/month for remotely monitoring physiolog-ic status. Approximately $26 of this $50estimate is allocated to the professional por-tion of the service (CPT code 93297),while the remaining amount is from thetechnical portion of the service (CPT code93299). The technical portion is still “con-tractor priced,” so physicians will see vari-ances in the actual reimbursement amountsfor this based on payer policy.

In addition to the compensationearned for monitoring the patient’s physi-ologic status, you will see an increase inoffice visits for patients at the earliest indi-cator of heart failure exacerbation. Many

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Uncertainty regarding which conditions justify each of the procedures you perform has a negative impact on profitability. This will cause rendered servicesto be denied for a lack of medicalnecessity, and it will prevent youfrom performing other services that would be compensated.

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electrophysiologists opt to not manage thepatient’s heart failure status. For thesepatients you could allow the referringphysician to enroll the patient in his/herheart failure clinic. This may solidify referralrelationships, and at the same time, it allowsthe patient and Medicare to enjoy the fullfunctionality of the implanted device.

#2: Hire Competent Coders andInvest in Their ContinuingEducation

The coding rules that apply to electro-physiology and cardiology are more com-plex than those of any other specialty.Allowing an unqualified person to codeyour procedures can easily result in a rev-enue loss of 30-40%, and it can expose youto tremendous liability since your name onevery claim attests to the accuracy of thereported codes. With the practicalities ofmaintaining a competent coding staff inmind, CardiologyCoder.Com offers amonthly proficiency test that confirmscoder comprehension of the guidelines pre-sented in each of its monthly newsletters.

The Certified Cardiology Coder (CCC)designation offered by the AmericanAcademy of Professional Coders (AAPC) isthe gold standard hallmark of competentcardiology and electrophysiology coders.Before earning the CCC designation, appli-cants are thoroughly tested with real-lifecase studies on each of the coding conven-tions that apply to cardiology and electro-physiology. After earning the credential,coders must maintain their skill set throughprescribed continuing education require-ments. Hiring a Certified CardiologyCoder or sponsoring your coders to earnthe designation provides assurance that yourcoding is being done by a competent pro-fessional. Information about test preparationand the certification can be found atwww.AAPC.com.

#1: Don’t Be Shy With Levels Fourand Five

The “bell curve” analysis payers use toeducate physicians about level of serviceselection is a brilliant piece of propaganda.These graphical illustrations show how yourlevel of service selection compares to otherphysicians, and they are typically only sentwhen you report more level four or five vis-its than government generated benchmarks.These graphs have successfully intimidatedphysicians into billing fewer level four andfive visits than they are providing. Level fourfollow-up visits (CPT code 99214) pay 50%more than level three follow-up visits (CPTcode 99213), and level five follow-up visits(CPT code 99215) pay twice the amountthat level three follow-up visits pay. Becauseof this, shying away from level four and five

services can immediately reduce your annu-al compensation by $30,000-$40,000.

The data you are compared to in thesebell curves is flawed, because it includesbilling data from all providers designated ascardiologists without recognizing the exis-tence of sub-specialties, they include datafrom registered nurses and mid-levelproviders who are billing under theirsupervising physician, they don’t recognizegeographic variances, and they illustrate the

end result of a fifteen-year intimidationeffort to scare physicians into underbillingservices. The documentation guidelines areterribly flawed and not linked to logic orpatient care. However, they make it veryeasy for electrophysiologists and cardiolo-gists to support level four or five visits forthe majority of encounters.

Since increased reporting of level fourand five visits is known to trigger payeraudits, make sure your documentation is in

line with the documentation guidelinesprior to reporting these higher level servic-es. In the hands of a competent educator,documentation guideline orientationrequires a physician investment of aboutone hour. For an effective and low-costphysician training option, make sure to visitour website.

For more information, please visit:www.cardiologycoder.com/

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