As part of the 2022 Medicare Physician Fee Schedule final rule, the Centers for Medicare and Medicaid Services (CMS) implemented reductions to work relative value units (RVUs) for electrophysiology (EP) ablation services without any modifications. These reductions essentially eliminate separate payment for 3D mapping, left-atrial pacing, and intracardiac echocardiography (ICE) when performed with supraventricular tachycardia (SVT) ablation and atrial fibrillation (AFib) ablation, as shown in the table below.

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	93653	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

The ACC and Heart Rhythm Society (HRS) staff and member leaders met multiple times with various agency officials and members of Congress to share information, questions and concerns on the physician fee schedule to ensure work RVU recommendations were clearly understood and informed by the best available information. The ACC also submitted formal written comments explaining information from a second work RVU survey and recommending a phase-in of reductions. However, the final rule made no changes to the original proposal.

While additional survey information was available from a resurvey for the April 2021 American Medical Association RVU Update Committee (RUC) meeting to check the accuracy of the January 2021 surveys, CMS finalized its proposal to maintain the current work RVUs of SVT code 93653 and AF code 93656, while discounting the work of the bundled components for 2022. The agency also indicated additional changes could be made for 2023 based on information from the resurvey, which was not incorporated into 2022 rates. Information from the resurvey generally aligned with the first survey in showing large reductions in time. In 2023, some values could go up slightly and others down slightly from what CMS finalized for 2022 if data from the second survey and recommendations are adopted.

RUC Recommendations From Resurvey

Service	2022 RUC Code	2022 RUC Time	2022 RUC RVU	2022 CMS Code	2022 CMS Time	2022 CMS RVU
SVT, 3D mapping, LA pacing	93653	213	15.00	93653	239	14.75
VT, 3D mapping, LA pacing	93654	291	18.10	93654	336	19.75
Additional SVT/VT	93655	60	7.00	93655	60	5.50
AF, 3D mapping, ICE	93656	263	17.00	93656	306	19.77
Additional AF	93657	60	7.00	93657	60	5.50

History of Coding Changes

Through its ongoing review of potentially misvalued services, the AMA 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.

Time is a key factor in fee-for-service RVU rate setting. Physician work surveys executed by the ACC and HRS in the fall 2020 for the RUC demonstrated notable reductions in procedure times. The reductions in time were significant for the bundled codes. The ACC and HRS launched additional surveys in winter 2021 to confirm the accuracy of the 2020 surveys. The 2021 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, 3D 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.

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 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

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)

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

Keywords: Atrial Fibrillation, Centers for Medicare and Medicaid Services, U.S., Pulmonary Veins, Ventricular Premature Complexes, Cardiac Catheters, Current Procedural Terminology, Medicare, Heart Atria, Catheter Ablation, Electrocardiography, Tachycardia, Supraventricular, Tachycardia, Ventricular, Echocardiography, Fluoroscopy, Catheterization, Fee Schedules, Electrophysiology, ACC Advocacy

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