Current Procedural Terminology Coding in Electrophysiology: Focus on 2009 Updates

ABSTRACT: This article highlights the major changes in the current procedural terminology codes (CPT codes) that were announced by the American Medical Association in January 2009. These new CPT codes were developed to more accurately reflect current cardiac device monitoring capabilities, long-distance telemetry and remote interrogation as well as follow-up practices. Some of these new code sets are structured differently than the CPT codes that they replace. Specifically, the new codes for remote monitoring do not have separate professional (-26) and technical components (-TC) applied to an individual code. Instead, the new remote monitoring codes have separate CPT codes that represent the professional and technical components. The new device programming codes are generally defined by the number of leads, rather than the type of generator. Also, the period of time included in the specific type of service is indicated as per encounter, 30 or 90 days. Furthermore, two new periprocedural device evaluation and programming codes have been introduced. Reprinted with permission from The Journal of Invasive Cardiology 2009;21:244–246. The importance of coding for services and procedures has evolved and increased rapidly in recent years. While initially looked upon as a method to classify the services and procedures provided by physicians, it has now evolved into a system used principally to determine the reimbursement received by physicians for their services. The rapid evolution of coding practices and policy has confused physicians and office personnel regarding how to code for physicians’ services. This is especially true for coding and billing in electrophysiology, where several different current procedural terminology codes (CPT) exist. In January 2009, at the request of the American college of Cardiology and the Heart Rhythm Society, the American Medical Association created 23 new CPT codes for cardiac device monitoring (CDM). The new CPT codes were created with the aim of recognizing the following: 1. Differentiation between the services associated with CDM, with special emphasis on the recent advances in cardiac device monitoring; 2. Differentiation between remote versus in-person monitoring; 3. Differentiation between interrogation and programming; 4. Coding differences when more than two leads systems (i.e., coronary sinus/LV pacing) are involved; 5. Periprocedural device interrogations; 6. Coding to report physiologic monitoring, i.e., transthoracic impedance, left atrial pressure, weight and blood pressure measurement; 7. Services associated with wearable mobile cardiovascular telemetry. The aim of this review is to highlight these important differences with an attempt to simplify billing from a cardiologist’s point of view. Details of the exact reimbursement fees have not been included in this review due to the lack of uniformity in reimbursement across the country for identical procedures. For the sake of convenience, the coding updates have been divided based on whether the device interrogation is done in person or remotely. The reader should note that the reimbursement rates are not identical for these different modes of device interrogation. The details of the actual CPT codes are shown in Figures 1–6. A list of discontinued CPT codes is shown in Table 1. Two examples of CPT coding in a clinical setting are shown in Table 2. The most important changes in CPT coding for cardiac rhythm monitoring devices are as follows: 1. Pacemaker interrogation: In-person pacemaker interrogation: a. Interrogation (which includes connection, recording and disconnection per patient encounter along with physician review and analysis) of single, dual and multi-chamber pacing are now bundled under one single code (93288). b. The term “programming” (which implies testing the function of device such as threshold testing, sensing and selecting optimal permanent programmed values) replaced the previous term “reprogramming” (implying a need for change in existing parameters). c. Separate CPT codes based on whether the device “programmed” is a single chamber (93279), dual chamber (93280) or multiple lead pacing system (93281). Remote interrogation and transtelephonic monitoring: a. Single code for interrogation of pacemaker (single, dual or multiple lead system). b. The new codes do not have separate professional (-26) and technical components (-TC) applied to an individual code. Instead, the separate CPT codes that represent the professional and technical components have been created (Figure 1). c. Frequency of permissible routine interrogation once every 90 days. d. Remote interrogation or in-person interrogation can be combined with transtelephonic monitoring once every quarter (90 days). 2. Implantable cardioverter defibrillator (ICD) The key difference for ICD CPT coding is similar to those for pacemakers (both in-person and remote). The actual CPT codes are shown in Figure 2. 3. Implantable cardiovascular monitor These include various cardiovascular physiology monitoring in the form of transthoracic impedances, OptiVol (Medtronic, Inc., Minneapolis, Minnesota) fluid status monitoring or blood pressure and weight monitoring. These can be conducted in-person (93290) or via remote monitoring (93297 and 93299), and can be performed on a monthly basis (Figure 3). 4. Implantable loop recorder The key differences are as follows: In-person: Separate coding for interrogation only (93291) versus interrogation and programming (93285). Remote: As a new addition to the CPT codes, this year’s update allows coding for a remote interrogation of a loop recorder (93298 and 93299 for professional and technical components). This can be performed once every 30 days (Figure 4). 5. Periprocedural interrogation and programming To avoid inappropriate coding, separate codes have been added for pacemaker interrogation and ICD turn-offs/turn-ons prior to and following any procedures or surgeries (93286 and 93287, respectively). Coding can be reported twice if an interrogation was prior to as well as subsequent to the surgery (Figure 2). 6. Mobile cardiovascular telemetry These include extended external monitoring devices such as CardioNet (CardioNet, Conshohocken, Pennsylvania) or LifeWatch (LifeWatch Corp., Rosemont, Illinois). A previously unlisted cardiovascular service, a new billing code 93228 has been included to describe the professional component of this service (Figure 5). 7. Wearable cardioverter defibrillator Two separate codes are included for wearable cardioverter defibrillators (LifeVest, ZOLL Lifecor Corp., Pittsburgh, Pennsylvania): one for initial physician set-up (93745) and one for subsequent interrogation and programming per encounter (93292) (Figure 6). Conclusion With advances in technology as well as widespread cuts in reimbursements for physician-provided services, it is imperative to become more educated about the different CPT codes. The new 2009 CPT coding in electrophysiology is an attempt made by the American Medical Association to assist in appropriate and ethical billing in the complex field of cardiac device monitoring.