Atrial Fibrillation Ablation: Go Big or Go Home!

The prevalence of atrial fibrillation (AF) and the achievable benefits offered by evolving ablation protocols are undeniable. As such, we can expect to see the volume of AF ablation cases continue to remain steady for years to come — potentially indefinitely. The demand for AF ablation and the gratitude received from cured patients make this a very attractive service to offer. However, the EP community may benefit from shifting the bulk of AF ablations to facilities and physicians dedicated to performing a high volume of atrial fibrillation ablations (AF Magnet centers). The financial lure of AF ablation is primarily limited to the volume of available cases. Several doctors have relayed (to me) that they are not turning away diagnostic EP studies, non-AF ablations, or device work for the sake of performing AF ablation; they view AF ablation as supplemental to these service lines. Many EPs also feel it is necessary to offer AF ablation in order to protect the referral relationships they have worked hard to cultivate. However, if AF ablations were consolidated into AF Magnet centers, those doctors specializing in AF ablation would not necessarily be competing for the same business. In 2010 and prior years, it was necessary to request additional compensation for AF ablation by submitting an unlisted procedure code (93799) for the transseptal puncture and/or attaching the complex procedure modifier (22) to the standard SVT ablation code (93651). Until 2009, these approaches frequently generated compensation of $300 - $1,000 in addition to the standard reimbursement rate for atrial flutter ablation. As soon as payers noticed the increased volume of “complex” and “unlisted” procedures, they ratcheted down or eliminated this premium. Many physicians attempted to secure additional compensation for these cases by reporting a diagnostic, right and left heart catheterization via a transseptal puncture (CPT code 93527). With or without the measurement of atrial blood pressure, the work associated with the transseptal puncture did not warrant compensation for this procedure code. Payers quickly caught onto the discrepancy and closed the door on this procedure with claim processing edits that prevent compensation for the diagnostic heart catheterization (93527) when reported on the same day as an SVT ablation (93651). CPT 2011 comes through with a “listed” procedure code that is intended to be used in addition to the SVT ablation code. Code 93462 is defined as “left heart catheterization by transseptal puncture through intact septum or by transapical puncture (list in addition to code for primary procedure)”. A parenthetical note under this new code indicates that the codes for SVT (93651) and VT (93652) ablations are appropriate “primary procedure” codes for this new “add-on” code ... simply stated, code 93462 is valued to reflect that the provider is already being compensated for the pre-op, intra-op, and post-op work associated with the ablation procedures — reporting 93462 just adds to the work of the in-process surgery. While this is a welcome addition to the CPT code structure, the reimbursement rate assigned to it in the 2011 Physician Fee Schedule Final Rule (about $150) mandates that physicians carefully evaluate if it is advantageous to perform AF ablations. Consideration of the profitability associated with specific procedures is critical now that EP payment rates have deteriorated significantly. In recent years, EPs have sustained major financial setbacks due to CMS’ elimination of consultation reimbursement and the application of CMS’ 50% multiple procedure payment reduction for many common EP procedures like an EP study at the time of an ablation or a defibrillation threshold test at the time of a defibrillator implant. When weighing your options, make sure to factor in the true costs associated with offering AF ablation. For many physicians and many facilities, it is advantageous to refer AF cases to Magnet centers. The income associated with performing a low volume of these procedures may not justify the tremendous investment required, including training, equipment, and radiation exposure. If you are busy performing a significant number of AF ablations, you are taking away from the time you could spend cultivating referrals, taking on new patients, and performing more lucrative services. While an AF ablation case will generate $150 more than a flutter ablation, you could realistically perform a flutter ablation, implant a BiV defibrillator, and conduct a new patient consultation in the same block of time required for the AF ablation. The consultation could trigger a considerable stream of revenue in the form of diagnostic procedures, therapeutic procedures, and follow-up visits that continues for months. The BiV defibrillator implant would lock you into an annuity of about $1,700/year if you follow the device and the patient’s heart failure remotely and see them in-person twice a year for threshold testing and routine follow-up. This annuity would be handsomely rewarded by a valuation specialist whenever you choose to sell your practice. As calculated as it sounds, $1,700/year per patient is a sustainable revenue stream that can easily have a value assigned to it (roughly 2.5 X annual receipts). On the other hand, mastery of AF ablation techniques only has value while in use. Rather than walking away from these cases with a marketable annuity, doctors leave with a considerable amount of accumulated radiation. Furthermore, successful procedures effectively terminate the physician/patient relationship. For the lab, the costs associated with offering a low volume of AF ablations are both opportunity- and capital-related. At the most basic level, AF ablation can chew up a substantial amount of EP lab time — this limits the number of cases that can be performed in the lab and cuts deeply into the lab’s revenue stream. The optimal approach to AF ablation has changed several times in recent years; many of these iterations suggest that labs need to purchase new equipment: 3D mapping systems, cardiac CTA, ICE, robotics, radiation shields, etc. The outlay of capital required for this equipment can be price prohibitive for many hospitals. Magnet centers may justify this investment and expect it to generate efficiencies that reduce the lab time and radiation associated with AF ablation cases. Any facility that partners with aspiring AF ablation masters and dedicates the capital needed to outfit safe, efficient labs might boast the title of “AF Ablation Magnet Center.” The profitability associated with reduced procedural time and the volume of potential cases should be ample stimulus to cultivate this niche. Similarly, the long-term profitability associated with focusing on non-AF ablation cases and the savings associated with not competing in this niche should be ample stimulus to justify referring patients to a blossoming Magnet center.

For more information, please visit www.cardiologycoder.com