What Medical Coders should know about Patent Foramen Ovale (PFO) for spot-on reimbursement
A well-known consensus around PFO is that about one-quarter of adults have 'patent' foramen ovale. This makes it quite prevalent, for most people it stays undiagnosed/under-diagnosed considering how problematic the PFO can be!
In this article we will go through the complexities of PFO Coding in 2023 and what medical coders and your billing department need to know to follow through for excellent reimbursement in your Cardiology practice!
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. Patent foreman ovale or PFO becomes a congenital condition when for some reason it stays behind as a malformation even when an infant’s lungs are matured.
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. When that happens certain diagnostic and interventional measures are to be taken to counter it.
Symptoms
Usually, PFO patent foramen ovale is diagnosed when tests are done for another health concern. Mostly, cryptogenic ischemic stroke is a neurological concern for example. Which 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 – Personal history of transient ischemic attack (TIA), and cerebral infarction without residual 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)
- Results of diagnostic testing performed to rule out other causes including, but not limited to, carotid disease, hypercoagulable states, or atrial fibrillation
- Documentation of an evaluation by a cardiologist and a neurologist and both agree that the stroke is likely embolic
How PFO is treated?
Most people with a patent foramen ovale don't need treatment until PFO may become a serious issue later in adult life. As discussed before the concern of PFO originates from another medical issue about PFO. At the neonatal stage, timely follow-up with a Pediatric Cardiologist can help identify PFO at an early stage.
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):
ICE-guided PFO closure procedure can be billed using the CPT 93580 (CardioSEALs or AMPLATZER™ Occluder devices and others). 93580 is billed with ICE or TEE procedure codes (If the physician performed any echocardiography during the procedure, they can also report codes from the range 93303 – 93317 (TTE, TEE) or intracardiac echocardiography 93662 (ICE) as appropriate.
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ASDs and VSDs
The implantation of the Amplatzer device should be reported under procedure code 93580. Procedure codes 93580 and 93581 include a right heart catheterization procedure (93501, 93529-93533) as well as the injection of contrast for atrial and ventricular angiograms (93539, 93543, 93555). These codes should not be reported separately in addition to codes 93580, 93581, or 93799 (duct occluder).
- Percutaneous transcatheter closure with implantation of the CardioSeal device should be reported under procedure code 93581.
- Closure of single ventricular septal defects should be reported under codes 33681, 33684, and 33688.
- Closure of multiple ventricular septal defects should be reported under codes 33675, 33676, and 33677.
The following codes may be reported for ASD, VSD, or combined ASD and VSD repairs. The tips under each code outline additional terms associated with the code, as well as highlight some of the work components that may or may not be specifically included in the code.
Several codes may be used to report atrial septal defect (ASD) repairs, ventricular septal defect (VSD) repairs, and combined ASD and VSD repairs.
The code that most accurately describes the procedure performed should be reported. For example, if an ASD (or patent foramen ovale [PFO]) and VSD repair are performed in the same session, the combined code 33647 must be reported; you cannot separately report an ASD (33641) and VSD (33681) repair code.
Atrial Septal Defect Repairs
33641 - Repair atrial septal defect, with cardiopulmonary bypass, with or without patch Secundum ASD. Patent foramen ovale (PFO) closure Partial closure PFO (neonatal TOF repair) Includes suture closure
33645 - Direct or patch closure, sinus venous ASD, with or without anomalous pulmonary venous drainage Includes Warden procedure
- 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). In circumstances where multiple ASDs are repaired in the same session, code 33641 (or the appropriate ASD repair code) only may be reported once. There is a medically unlikely edit (MUE) of “1” for Medicaid and Medicare for the ASD and VSD codes. An MUE typically represents the maximum number of units reportable on the same date of service. If different types of ASDs are repaired, such as a secundum or PFO (33641) and an ostium primum ASD (33660), both codes may be reported.
33660 - Repair of incomplete or partial atrioventricular canal (ostium primum atrial septal defect), with or without atrioventricular valve repair
- Ostium Primum ASD
- Atrioventricular (AV) septal defect or endocardial cushion defect
- Report 33641 with 51 modifier and appropriate 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 - Repair of intermediate or transitional atrioventricular canal, with or without atrioventricular valve repair
Check the bundling edits for the codes; some coding combinations are bundled and will require an appropriate unbundling modifier (e.g., 59) in addition to the multiple procedure modifier (51).
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 atrial septal defect and ventricular septal defect, with direct or patch closure. We can't use 63 modifiers (Procedure Performed on Infants less than 4 kg).
It does not matter if the ASD or VSD is closed primarily (suture closure) or with a patch; the same code is used in either case. For the multiple VSD codes (33675, 33676, 33677), the code can be used only once per session—i.e., 33675 is used once for closing two, three, or more VSDs. Also, one cannot use the single VSD closure codes (33681, 33684, 33688) at the same time as the multiple VSD closure codes.
Final Take
If you have insurance through your employer or pay for private insurance, PFO closure is most likely covered. Check the insurance policy for coverage criteria and exclusions. Following up with proper documentation also helps in accurate codes and excellent reimbursement. We suggest also following up with Coverage determinant policy for related procedures to ensure billing is CMS compliant when it comes to proper guidelines.
AltuMED is one of the leading Medical Billing Services and Solutions Companies in the Healthcare industry. Our Medical Billing and Coding experts are committed to helping you improve the accuracy, efficiency, and productivity of your Medical Practice. Contact us to find out more!
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