As part of the proposed 2022 Medicare Physician Fee Schedule, the Centers for Medicare and Medicaid Services (CMS) is proposing reduced work RVUs for EP ablation services.

Through its ongoing review of potentially misvalued services, the American Medical Association (AMA) Relative Value-Scale Update Committee (RUC) in 2019 flagged EP ablation services for scrutiny because of significant growth in volume. While the growth in services is appropriate and reflects evolving patterns of care in the past decade, it also reflects changes in performance of the services themselves. When the current codes and descriptors were written in 2011, 3D mapping, left-atrial pacing, and ICE were not typically performed with the underlying ablations. However, with new technology and clinical practices, these services are now nearly universally performed with SVT and/or AFib ablations.

As such, while the CPT® code numbers remain the same for these services, two of the five codes underwent significant revisions of code descriptors to incorporate (bundle) related services. These revisions would also translate to the add-on codes for additional ablations. Starting in 2022, these components will not be separately reportable.

The revised code descriptors are shown below, with bolded phrases showing the newly bundled work.

93653: Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording, and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed 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

93564: Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording, and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of ventricular tachycardia or focus of ventricular ectopy including left ventricular pacing and recording, when performed

93655: 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)

93656: Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation, including intracardiac electrophysiologic 3-dimensional mapping, intracardiac echocardiography including imaging supervision and interpretation, induction or attempted induction of an arrhythmia including left or right atrial pacing/recording, right ventricular pacing/recording, and His bundle recording, when performed

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 (List separately in addition to code for primary procedure)

Time is a key factor in fee-for-service RVU rate setting. Physician work surveys executed by the ACC and Heart Rhythm Society (HRS) in the fall of 2020 for the RUC demonstrated notable reductions in procedure times. The reductions in time were significant for the bundled codes. Additional surveys were launched by ACC and HRS in the winter of 2021 to check the accuracy of the first. Those surveys also showed significant reductions in procedure times.

Shorter procedure times are likely due to a variety of factors, including improved systems that offer more detailed and accurate anatomical and electrical activation mapping, often completely eliminating the need for fluoroscopy. Catheter technology has also advanced, providing real-time assessment of the quality of contact between the catheter tip and the endocardial tissue. Additionally, 3-D mapping systems that function in concert with new catheter technology now provide real-time assessment of the quality of the radiofrequency ablation lesion formation, allowing shorter duration of each radiofrequency application while also improving the quality of the lesions delivered.

Because additional surveys were underway for the April RUC meeting to check the accuracy of the January surveys to resolve any flaws from the initial survey, such as survey respondents probably not realizing that a new descriptor includes services is now bundled to the existing CPT code (and not a newly issued CPT code), CMS proposes to maintain the current work RVUs of SVT code 93653 and AF code 93656 until the AMA RUC returns with a more definitive and accurate valuation based on feedback from additional surveys conducted this past spring to to ensure survey participants understand that a new descriptor includes services now bundled to the existing CPT code (and not a newly issued CPT code). As written, this would represent a reduction commensurate with the RVUs for the newly-bundled add-on services. The Agency also disagreed with the RUC-recommended values for the two add-on codes, 93655 and 93657, proposing to further reduce those. Additional refinement and possible reductions are possible as part of the final 2022 rulemaking.

ACC and HRS staff and member leaders continue to share information, questions, and concerns with AMA and CMS staff working on the physician fee schedule to ensure proposals are clearly understood and informed by the best available information. After two rounds of work RVU surveys completed by ACC and HRS members, some reduction in RVUs reflecting decreased effort and complexity is likely to be finalized. A table showing these differences are displayed below. The ACC will submit formal comments to CMS on this topic in September. Members can also share their insights or concerns about how reduced work RVUs would impact patients directly to the agency here.

Ablation Coding Format

Service	2021 Code(s)	2021 Time	2021 RVU		2022 Code	2022 Time	2022 RVU
SVT, 3D mapping, LA pacing	93653, 93613, 93621	359	22.08		93563	239	14.75
VT, 3D mapping, LA pacing	93654	309	19.75		93654	336	19.75
Additional SVT/VT	93655	90	7.50		93655	60	5.50
AF, 3D mapping, ICE	93656, 93613, 93662	424	26.44		93656	306	19.77
Additional AF	93657	90	7.50		93657	60	5.50

Clinical Topics: Arrhythmias and Clinical EP, Noninvasive Imaging, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: ACC Advocacy, Atrial Fibrillation, Centers for Medicare and Medicaid Services, U.S., Pulmonary Veins, Ventricular Premature Complexes, Cardiac Catheters, Coronary Sinus, Relative Value Scales, Current Procedural Terminology, Fee-for-Service Plans, American Medical Association, Bundle of His, Drug Repositioning, Medicare, Heart Atria, Catheter Ablation, Tachycardia, Supraventricular, Tachycardia, Ventricular, Echocardiography, Fluoroscopy, Catheterization, Health Policy

< Back to Listings