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References 1 International Classification of Diseases, Ninth Revision of Clinical Modification. http://www.cdc.gov/nchs/icd/icd9cm.htm. 2 International Classification of Diseases, Tenth Revision, Procedure Coding System. https://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-PCS-andGEMs.html. 3 International Classification of Diseases, Tenth Revision, Clinical Modification. http://www.cdc.gov/nchs/icd/icd10cm.htm. 4 Social Security Act Section 1862 42 U.S.C. 1395y(a)(1)(A), is available at http://www.ssa.gov/OP_Home/ssact/title18/1862.htm. 5 Current Procedural Terminology (CPT) is copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative causes or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for the data contained or not contained herein. Brief Statement (for Arctic Front Advance™ Cardiac CryoAblation Catheter, CryoConsole and Freezor™ MAX Cardiac CryoAblation Catheter) Indications Medtronic CryoCath™ CryoAblation system is comprised of cryoablation catheters and a CryoConsole. The Arctic Front Advance ST Cardiac CryoAblation Catheter system is indicated for the treatment of drug refractory recurrent symptomatic paroxysmal atrial fibrillation. The Freezor MAX Cardiac CryoAblation Catheter is used as an adjunctive device in the endocardial treatment of paroxysmal atrial fibrillation in conjunction with the Arctic Front Advance Cryoballoon. Please read the specific product labeling indications for use before using the cryoablation system. Contraindications Use of Arctic Front Advance ST Cryoballoon is contraindicated as follows: n in the ventricle because of the danger of catheter entrapment in the chordae tendinae n in patients with active systemic infections n i n conditions where the manipulation of the catheter within the heart would be unsafe (e.g.,intracardiac mural thrombus) n i n patients with cryoglobulinemia n in patients with one or more pulmonary vein stents Use of Freezor MAX cryocatheter is contraindicated in patients with the following conditions: n a ctive systemic infections n cryoglobulinemia n other conditions where the manipulation of the catheter would be unsafe (e.g., intracardiac mural thrombus) Warnings and Precautions Do not resterilize the cryoablation catheters for purpose of reuse. Use only the appropriate size of the FlexCath™ Steerable Sheath family with the Arctic Front Advance cryoablation catheters because using another sheath may damage the catheter or balloon segment. Do not inflate the balloon inside the sheath. Always verify with fluoroscopy or by using the proximal shaft visual marker that the balloon is fully outside the sheath before inflation to avoid catheter damage. Do not position the balloon within the tubular portion of the pulmonary vein to minimize phrenic nerve injury and pulmonary vein stenosis. Do not connect the cryoablation catheter to a radiofrequency (RF) generator or use it to deliver RF energy because this may cause catheter malfunction or patient harm. The catheter contains pressurized refrigerant during operation; release of this gas into the circulatory system due to equipment failure or misuse could result in gas embolism, which can occlude vessels and lead to tissue infarction with serious consequences. Always advance and withdraw components slowly to minimize the vacuum created and therefore minimize the risk of air embolism. Do not pull on the catheter, Medtronic 710 Medtronic Parkway Minneapolis, MN 55432-5604 USA Tel: (763) 514-4000 Fax:(763) 514-4879 medtronic.com Toll-free: 1 (800) 328-2518 (24-hour technical support for physicians and medical professionals) UC201406308b EN © Medtronic 2015. Minneapolis, MN. All Rights Reserved. Printed in USA. 10/2015 sheath, umbilical cables, or console while the catheter is frozen to the tissue, as this may lead to tissue injury. Do not advance the balloon beyond the guide wire to reduce risk of tissue damage. Do not pass the catheter through a prosthetic heart valve (mechanical or tissue) to avoid damage to the valve, valvular insufficiency, or premature failure of the prosthetic valve. Always inflate the balloon in the atrium then position it at the pulmonary vein ostium to avoid vascular injury. Do not ablate in the tubular portion of the pulmonary vein. Monitor the status of the phrenic nerve continuously during right-sided pulmonary vein applications using an appropriate monitoring technique. Stop ablation immediately if phrenic nerve impairment is observed. Consider appropriate medical strategies to minimize the risk of damage to the lung or tracheobronchial tree and the risk of esophogeal injury. Use appropriate levels of contrast media in patients with comorbidities. Follow contrast labeling and institutional procedures regarding the appropriate medical strategies to minimize risk when using contrast media. The CryoAblation (Arctic Front Advance and Freezor MAX) family of catheters were not studied for safety of changes in anticoagulation therapy in patients with atrial fibrillation. This equipment should be used only by or under the supervision of physicians trained in left-atrial cryoablation procedures. Cryoablation procedures should be performed only in a fully equipped facility. Potential Complications Potential complications/adverse events that may be associated with cardiac catheterization and ablation listed alphabetically below include but are not limited to: anemia; anxiety; atrial flutter; back pain; bleeding from puncture sites; blurred vision; bradycardia; bronchial constriction, bronchitis; bruising; cardiac tamponade; cardiopulmonary arrest; cerebral vascular accident; chest discomfort/pain/pressure; cold feeling; cough; death; diarrhea; dizziness; esophageal damage (including esophageal fistula); fatigue; fever; gastroparesis; headache; hemoptysis; hypotension/ hypertension; lightheadedness; myocardial infarction; nausea/vomiting; nerve injury; pericardial effusion; pulmonary vein stenosis; shivering; shortness of breath; sore throat; tachycardia; transient ischemic attack; urinary infection; vasovagal reaction; visual changes. Refer to the device technical manual for detailed information regarding the procedure, indications, contraindications, warnings, precautions, and potential complications/adverse events. For further information, please call Medtronic at 1 (800) 328-2518 and/or consult Medtronic’s website at www.medtronic.com. Caution: Federal law (USA) restricts this device to sale by or on the order of a physician. CATHETER ABLATION REIMBURSEMENT GUIDE Updated October 1, 2015 TABLE OF CONTENTS ABLATION CATHETERS Ablation Catheters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Arctic Front™, Arctic Front Advance™, and Arctic Front Advance™ ST Cardiac CryoAblation Catheters CryoAblation Catheters n Arctic Front™ Cardiac CryoAblation Catheter, Arctic Front Advance™ Cardiac CryoAblation Catheter, Arctic Front Advance™ ST Cardiac CryoAblation Catheter, Freezor™ Cardiac CryoAblation Catheter, Freezor™ MAX Cardiac CryoAblation Catheter Conventional Radiofrequency (RF) Ablation Catheters n Marinr™ Conventional Radiofrequency (RF) Ablation Catheter, RF Conductr™ MC Conventional Radiofrequency (RF) Ablation Catheter, and RF Contactr™ Conventional Radiofrequency (RF) Ablation Catheter, Enhancr™ Conventional Radiofrequency (RF) Ablation Catheter Catheter Indication Arctic Front , Arctic Front Advance™, and Arctic Front Advance™ ST Cardiac CryoAblation Catheters ™ Treatment of drug refractory recurrent symptomatic Paroxysmal Atrial Fibrillation (PAF) Medicare Other Payers The Arctic Front™, Arctic Front Advance™, and Arctic Front Advance™ ST Cardiac CryoAblation catheters deliver refrigerant (via the CryoConsole) through an inflatable balloon to remove heat from tissue, freezing and disabling unwanted electrical circuits in the pulmonary veins that may contribute to PAF. The Cryoballoon’s shape achieves contact over a broad area to create the barriers that prevent these electrical currents from entering the heart’s atria. The FlexCath™ and the FlexCath Advance™ Steerable Sheaths position the Arctic Front™, Arctic Front Advance™, and Arctic Front Advance™ ST Cardiac Cryoballoon in the heart. Physician Services Coding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Freezor™ Cardiac CryoAblation Catheters Coverage for Catheter Ablation Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Catheter Ablation Diagnostic Electrophysiologic Study (EPS) Catheter Indication and Use Inpatient Hospital Coding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Freezor™ Cardiac CryoAblation Catheter Treatment of Atrioventricular Nodal Re-entry Tachycardia (AVNRT). ICD-9-CM1 crosswalk to ICD-10-PCS2 Procedure Codes Medicare Severity Diagnosis Related Group (MS-DRG) Assignments Freezor™ MAX Cardiac CryoAblation Catheter Treatment of PAF. Used in conjunction with the Arctic Front Advance™ Cryoballoon to: • Provide touch-up cryoablation and complete the Pulmonary Vein Isolation (PVI) process as needed • Cryoablate focal trigger sites • Create the ablation line between the inferior vena cava and the tricuspid valve Outpatient Hospital Coding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Comprehensive Ambulatory Payment Classification (C-APCs): Medicare Hospital Outpatient Catheter Ablation C-Code Listing Diagnosis Coding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 ICD-9-CM crosswalk to ICD-10-CM3 Diagnosis Codes The Freezor™ and Freezor™ MAX Cardiac CryoAblation Catheters are deflectable, single-use, electrophysiology catheters designed to ablate cardiac tissue using cryothermal energy. Refrigerant is directed via the CryoConsole through these devices, creating precise, focal lesions. Conventional Radiofrequency (RF) Ablation Catheters For questions or for more information, please contact Medtronic at 1 (866) 877-4102. Catheter Indication RF Marinr MC Multi-Curve Steerable Ablation Catheter RF catheters are indicated for use with the Medtronic RF generator to deliver RF energy for intracardiac ablation of accessory atrioventricular (AV) conduction pathways associated with tachycardia for the treatment of AV nodal re-entrant tachycardia (AVNRT) and for creation of complete AV block in patients with a difficult to control ventricular response to an atrial arrhythmia. ™ The coding suggestions and coding guidelines in this guide do not replace seeking coding advice from the payer and/or your own coding staff. The ultimate responsibility for correct coding lies with the provider of services. Please contact your local payer for interpretation of the appropriate codes to use for specific procedures. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other third-party payers as to the correct form of billing or the amount that will be paid to providers of service. Where reimbursement is requested for the use of a product that may be inconsistent or not expressly specified in the FDA cleared or approved labeling (e.g., instructions for use, operator’s manual, or package insert), consult with your billing advisors or payers for advice on handling such billing issues. Some payers may have policies that make it inappropriate to submit claims for such items or related services. RF Marinr™ SC Single-Curve Steerable Ablation Catheter RF Conductr™ MC Multi-Curve Bidirectional Ablation Catheter RF Contactr™ Dual-Curve Ablation Catheter RF Enhancr™ II Single-Curve Ablation Catheter Conventional RF Ablation Catheters are used in conjunction with a Medtronic RF power generator to produce therapeutic, heat-based energy at a targeted area of cardiac tissue. RF energy, delivered via the catheter, destroys tissue integral to the onset and maintenance of most atrial tachyarrhythmias. 2 of 7 October 2015 3 of 7 October 2015 COVERAGE FOR CATHETER ABLATION PROCEDURES Medicare: Medicare has not issued national or local coverage determinations for catheter ablation services. The Social Security Act allows coverage and payment for only those services that are considered to be medically reasonable and necessary.4 The medical necessity for services provided must be documented in the medical record. Other Payers: We recommend that you contact the patient’s insurance company for guidance on what specific CPT™5 codes are required for catheter ablation procedures as part of your request for a prior authorization or a pre-determination. PHYSICIAN SERVICES CODING 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 (Use 93655 in conjunction with 93653-4, 93656) +93657 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 (Use 93657 in conjunction with 93656) +93462 Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (Use 93462 in conjunction with 93452-3, 93458-93461, 93582, 93653-4) (Do not report 93462 in conjunction with 93656) When reporting ablation therapy codes (93653 – 93657), comprehensive EP studies may not be separately reported. Coding information to be used when a physician performs a diagnostic Electrophysiologic Study (EPS) prior to a catheter ablation. Some of the CPT5 codes used to describe EP diagnostic and cardiac catheter ablation procedures, as well as mapping procedures, which may sometimes be concurrently performed at physician’s discretion, are listed below. Catheter Ablation: CPT5 Code CPT5 Code Description 93650 Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement 93653 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 (Do not report 93653 in conjunction with 93600-3, 93610, 93612, 93618-20, 93642, 93654, 93656) 93656 +93655 Diagnostic Electrophysiologic Study (EPS): Significant changes were made to the CPT5 codes for catheter ablation procedures for services performed on and after January 1, 2013. Both the catheter ablation and electrophysiological study (EPS) aspects of the procedure are reflected in the new catheter ablation codes. In some instances, the catheter ablation and EPS procedures are no longer considered distinct procedures and therefore not reportable with separate codes. 93654 Add-on codes +93655 and +93657 may be applicable when intracardiac catheter ablation of a discrete arrhythmia is performed after the treatment of the primary ablated mechanism. …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 (Do not report 93654 in conjunction with 93279-84, 93286-9, 93600-3, 93609-10, 93612-3, 93618-20, 93622, 93642, 93653, 93656) 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 (Do not report 93656 in conjunction with 93279-84, 93286-9, 93462, 93600, 93602-3, 93610, 93612, 93618-21, 93653-4) CPT5 Code CPT5 Code Description 93619 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 (Do not report 93619 in conjunction with 93600, 93602-3, 93610, 93612, 93618, 93620-2, 93653-7) 93620 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 (Do not report 93620 in conjunction with 93600, 93602-3, 93610, 93612, 93618-9, 93653-7) +93621 …with left atrial pacing and recording from coronary sinus or left atrium (Use 93621 in conjunction with 93620, 93653-4) (Do not report 93621 in conjunction with 93656) +93622 …with left ventricular pacing and recording (Use 93622 in conjunction with 93620, 93653, 93656) (Do not report 93622 in conjunction with 93654) +93623 Programmed stimulation and pacing after intravenous drug infusion (Use 93623 in conjunction with 93610, 93612, 93619-20, 93653-4, 93656) +93662 Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation (Use 93662 in conjunction with 92987, 93453, 93460-2, 93532, 93580-1, 93620-2, 93653-4, 93656 as appropriate) 93624 Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy, including induction or attempted induction of arrhythmia Mapping is considered a distinct procedure performed in addition to a diagnostic EP study or ablation procedure +93609 Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (Use 93609 in conjunction with 93620, 93653, 93656) (Do not report 93609 in conjunction with 93613, 93654) +93613 Intracardiac electrophysiologic 3-dimensional mapping (Use 93613 in conjunction with 93620, 93653, 93656) (Do not report 93613 in conjunction with 93609, 93654) The ablation procedure codes 93653, 93654 and 93656 are distinct primary procedure codes and may not be reported together. 4 of 7 October 2015 5 of 7 October 2015 INPATIENT HOSPITAL CODING Medicare Hospital Outpatient Catheter Ablation C-Code Listing For CY 2015, Medicare requires that only a single appropriate device code is submitted on the claim for the procedure. C1733 – Catheter, Electrophysiology, Diagnostic/Ablation, Other than 3D or Vector Mapping, Other than Cool Tip Device ICD-9-CM crosswalk to ICD-10-PCS Procedure Codes for discharges after September 30, 2015 1 2 Please note that there is not always a direct crosswalk from ICD-9-CM to ICD-10-PCS. It is up to the provider to select the appropriate code(s) to represent the procedure(s) performed. The following list is not all-inclusive. ICD-9-CM1 Procedure Code 37.26 37.27 37.34 ICD-9-CM1 Procedure Code Description ICD-10-PCS2 Procedure Code Catheter based invasive 4A023FZ electrophysiologic testing Cardiac mapping 02580ZZ* Excision or destruction of other lesion or tissue of 02583ZZ heart, endovascular approach ICD-10-PCS Procedure Code Description 2 Measurement of Cardiac Rhythm, Percutaneous Approach Destruction of Conduction Mechanism, Open Approach Destruction of Conduction Mechanism, Percutaneous Approach Possible DRG Assignments (MS-DRG: Medicare Severity Diagnosis Related Group) Brief MS-DRG Description 273 274 Percutaneous intracardiac procedures w/MCC Percutaneous intracardiac procedures w/o MCC CPT4 Code Brief Description 93619 93620 93624 93650 93653 93654 93656 Electrophysiology evaluation Electrophysiology evaluation EP follow-up study AV node ablation SVT ablation and EP eval VT ablation and EP eval Ablation of AF by PVI with transseptal and EP evaluation +93622 +93623 +93655 +93657 +93662 6 of 7 075302, 075305, 075312, 075402, 075405 5F RF Marinr 076514, 076515, 076583, 076584, 076585, 076586 RF Enhancr II 31744523, 31745523, 31745533, 39745533, 39746534 Freezor™ Cardiac CryoAblation Catheter 307F1, 307F3, 307F5 Freezor MAX Cardiac CryoAblation Catheter 239F3, 239F5 Arctic Front™ Cardiac CryoAblation Catheter 2AF232, 2AF282 Arctic Front Advance Cardiac CryoAblation Catheter 2AF234, 2AF284 Arctic Front Advance™ ST Cardiac CryoAblation Catheter 2AFAST23, 2AFAST28 ™ ™ ™ C1766 – Introducer/Sheath, Guiding, Intracardiac Electrophysiological, Steerable, Other than Peel-Away Device Model Number FlexCath Steerable Sheath 3FC10, 3FC12 FlexCath Advance Steerable Sheath 4FC12 Device Model Number Torqr CS Diagnostic Catheter 041565CS, 041590CS, 041865CS Torqr,™ Soloist™ Diagnostic Catheter 041002JM, 041002UM, 041005DM, 041005JM, 041005UM, 04120DS, 04122JM, 04122UM, 04125JM, 04125UM, 441016JF, 441016U, 44216J, 44216JF, 44216U, 44516J, 44516JF, 44516U Marinr™ CS 043302M, 043325M, 043328M Marinr™ 072302, 072322M, 072402 ™ C-APC C-APC Description 0085 Level II Electrophysiologic Procedures 0086 Level III Electrophysiologic Procedures The following codes are not assigned to an APC as they are ancillary to the primary procedures. Medicare classifies the following codes with an “N” Status Indicator and does not separately reimburse hospitals for these procedures. Hospitals should report all applicable codes, including those for packaged services, according to correct coding principles. +93621 RF Marinr™ MC C1730 – Catheter, Electrophysiology, Diagnostic, Other than 3D Mapping (19 or Fewer Electrodes) Comprehensive Ambulatory Payment Classifications (C-APCs): +93613 0786022, 0786042, 0787533, 0787544, 07857544, 07856042, 07856044, 0786044, 0787544 ™ OUTPATIENT HOSPITAL CODING +93609 70256034, 70257533 ™ MCC: Major complication or comorbidity +93462 RF Contactr RF Conductr™ MC ™ *AHA Coding Clinic for ICD-10-CM and ICD-10-PCS, Volume 1 Number 4, Fourth Quarter 2014. MS-DRG Model Number ™ Transseptal puncture (Use 93462 in conjunction with 93452-3, 93458-61, 93461, 93582-4) (Do not report 93642 in conjunction with 93656) Intraventricular and/or intra-atrial mapping (Use 93609 in conjunction with 93620, 93653, 93656) (Do not report 93609 in conjunction with 93613, 93654) Intracardiac 3-dimensional mapping (Use 93613 in conjunction with 93620, 93653, 93656) (Do not report 93613 in conjunction with 93609, 93654) Comprehensive EP evaluation; with left atrial pacing and recording from coronary sinus or left atrium (Use 93621 in conjunction with 93620, 93653-4) (Do not report 93621 in conjunction with 93656) Comprehensive EP evaluation; with left ventricular pacing and recording (Use 93622 in conjunction with 93620, 93653, 93656) (Do not report 93622 in conjunction with 93654) Programmed stimulation and pacing after intravenous drug infusion (Use 93623 in conjunction with 93610, 93612, 93619-20, 93653-4, 93656) Additional ablation of discrete arrhythmia, SVT or VT (Use 93655 in conjunction with 93653-4, 93656) Additional linear focal lesion for AF (Use 93657 in conjunction with 93656) Intracardiac echocardiography (Use 93662 in conjunction with 92987, 93453, 93460-2, 93532, 93580-1, 93620-2, 93653-4, 93656 as appropriate) (Do not report 92961 in addition to 93662) October 2015 Achieve Mapping Catheter 990063-015, 990063-020 ™ C1731 – Catheter, Electrophysiology, Diagnostic, Other than 3D Mapping (20 or More Electrodes) Device StableMapr™ Model Number 04401SM, 04402SM DIAGNOSIS CODES ICD-9-CM1 crosswalk to ICD-10-CM3 Diagnosis Codes for discharges after September 30, 2015 Please note that there is not always a direct crosswalk from ICD-9-CM1 to ICD-10-CM.3 It is up to the provider to select the most appropriate diagnosis code(s). The following list is for illustrative purposes only and is not all-inclusive. ICD-9-CM1 Diagnosis Code ICD-9-CM Diagnosis Code Description 427.31 Atrial fibrillation 427.32 Atrial flutter 427.0 Paroxysmal supraventricular tachycardia 7 of 7 1 ICD-10-CM3 Diagnosis Code ICD-10-CM3 Diagnosis Code Description I48.0 I48.3 I48.4 I48.92 I47.1 Paroxysmal atrial fibrillation Typical atrial flutter (type I) Atypical atrial flutter (type II) Unspecified atrial flutter Supraventricular tachycardia (includes AVNRT) October 2015