What Medical Coders should know about Patent Foramen Ovale (PFO) for spot-on reimbursement
Approximately one-quarter of adults have a 'patent' foramen ovale (PFO). A quarter of adults have an undiagnosed PFO, which can be problematic!
This article covers 2023 PFO coding for excellent cardiology reimbursement!
What is PFO?
A ‘foramen ovale’ is an opening that allows blood to go around the lungs in developmental stages. Which later closes and its functionality is replaced by lungs post-birth. PFO is a congenital malformation that persists despite lung maturation.
Describing PFO
PFO, for the most part, stays dormant, without causing any problems. Until some complications and comorbidities force it to come to the surface. PFO may require diagnostic and interventional measures.
Symptoms
PFO is often diagnosed incidentally during tests for other health issues. Mostly, cryptogenic ischemic stroke is a neurological concern, for example. This might lead to further investigation, including imaging and tests to confirm diagnosis.
ICD-10-CM Diagnosis Codes that could be used:
163.9 – Stroke / Cerebral infarction, unspecified
Z86.73 – History of TIA and cerebral infarction without deficits
G43.909 – Migraine Prevention
R51.9 – Headaches
Q21.21 – Partial atrioventricular septal defect
Medical notes documenting the following, when applicable:
- History and co-morbid medical condition(s)
- Documentation of member’s symptoms
- Complete report(s) of diagnostic imaging (MRI, CT scan, x-rays)
- Diagnostic tests to rule out other causes like carotid disease, hypercoagulability, & atrial fibrillation.
- Evaluation by cardiologist and neurologist agreeing the stroke is likely embolic.
How PFO is treated?
Most PFOs don't require treatment until adulthood. Pediatric cardiology follow-up can identify PFO early.
Classification
When treatment for a PFO is needed, it may include:
- Therapeutic Intervention
- Diagnostic/Interventional via Catheterization and PCI
- Surgical Intervention for Closure
PFO/ASO Closure with ICE (93580 with 93662):
Bill ICE-guided PFO closure with CPT 93580 (CardioSEALs, AMPLATZER™ Occluder, etc.). Bill 93580 has ICE/TEE codes if echocardiography was performed during PFO closure.
ASDs and VSDs
The implantation of the Amplatzer device should be reported under procedure code 93580. Codes 93580 & 93581 do not include right heart catheterization & contrast injections for angiograms. Do not report these codes separately with 93580, 93581, or 93799.
- Use code 93581 for percutaneous closure with CardioSeal device implantation.
- Report closure of single ventricular septal defects with codes 33681, 33684, and 33688.
- Use codes 33675, 33676, and 33677 for closure of multiple ventricular septal defects.
The following codes may be reported for ASD, VSD, or combined ASD and VSD repairs. The code tips outline associated terms and include work components.
Codes for ASD, VSD, and combined ASD/VSD repairs vary.
The code that most accurately describes the procedure performed should be reported. Use code 33647 for combined ASD and VSD repair; do not report separate ASD and VSD repair codes.
Atrial Septal Defect Repairs
33641 - Repair atrial septal defect with cardiopulmonary bypass, with or without patch.
33645 - Closure of sinus venous ASD with & without anomalous pulmonary venous drainage.
- Can't be used with 33724 - partial anomalous pulmonary venous connection (scimitar syndrome)
- Can't be used with 33726 - pulmonary venous stenosis
There is no code for the repair of multiple ASDs, as there is for the closure of multiple VSDs (33675, 33676, and 33677). Report code 33641 only once for multiple ASD repairs in the same session. There is a medically unlikely edit (MUE) of “1” for Medicaid and Medicare for the ASD and VSD codes. MUE is the maximum reportable units on the same date. Report different ASD types separately, e.g., 33641 and 33660.
33660 - Repair of partial atrioventricular canal (ostium primum ASD), ± valve repair.
- Ostium Primum ASD
- Atrioventricular (AV) septal defect or endocardial cushion defect
- Use 33641-51 with unbundling modifier for additional secundum ASD or PFO repairs.
- Repair of the common atrium or partition of the common atrium—use 33641 or 33660
- Can't be used with mitral valve repair or annuloplasty codes
33665 - Use 33641-51 with unbundling modifier for additional secundum ASD or PFO repairs.
Check bundling edits; some code combinations require 51 and an unbundling modifier.
Restrictive VSD component
Ventricular Septal Defect Repairs
- 33681 - Closure of ventricular septal defect, with or without patch; (includes suture closure)
- 33684 - with pulmonary valvotomy or infundibular resection (cyanotic)—double-chambered right ventricle
- 33688 - with the removal of pulmonary artery band, with or without gusset
- 33675 - Closure of multiple ventricular septal defects;
- 33676 - with pulmonary valvotomy or infundibular resection (cyanotic)
- 33677 - with removal of pulmonary artery band, with or without gusset
Combined ASD and VSD Repair
33647 - Repair of ASD and VSD with direct or patch closure.
We can't use 63 modifiers (Procedure Performed on Infants less than 4 kg).
The same code is used for ASD or VSD closure, whether sutured or patched. Use 33675-77 once for multiple VSDs; no 33681-88 with 33675-77.
Final Take
Employer or private insurance usually covers PFO closure. Check the insurance policy for coverage criteria and exclusions. Following up with proper documentation also helps in accurate codes and excellent reimbursement. Follow up with coverage determinant policy for related procedures to ensure CMS-compliant billing.
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