AtriCure 2024 Cardiac Ablation and Left Atrial Appendage Management Instructions

**AtriCure 2024 Cardiac Ablation and Left Atrial Appendage Management Instructions

**

Introduction

This information is shared for educational purposes and current as of March 15, 2024. Healthcare providers are solely responsible for the accuracy of codes selected for the services rendered and reported in the patient’s medical record. AtriCure does  not assume responsibility for coding decisions, nor recommend codes for specific cases. Items and services that are billed to payers must be medically necessary and supported by appropriate documentation. AtriCure does not promote the off-label use of its devices. While a code may exist describing certain procedures and/or technologies, this does not guarantee payment by payers.

Product Offerings

AtriCure product offerings include, but are not limited to, BiPolar Radiofrequency (RF) and Cryoablation surgical ablation devices; the AtriClip® Left Atrial Appendage Management System (LAAM); EPi-Sense® coagulation device, LARIAT® suture delivery device and cryoICE® Cryo Nerve Block (cryoNB).

Table 1. Physician Coding and Reimbursement

Current Procedure Terminology (CPT®) are codes describing the procedure during the patient visit. CPT codes that may be appropriate for procedures used in conjunction with cardiac ablation surgery, catheter ablation or LAAM are included below.

CY 2024 CY 2024     CY 2024

Physician Work Physician National Relative Value Total                              Payment

CPT*             Description Units (RVUs)                      RVU Rate §

Cardiac Surgical Ablation
33250| Operative ablation of supraventricular arrhythmogenic focus or pathway without cardiopulmonary bypass| 25.90| 42.78| $1,226
33251| Operative ablation of supraventricular arrhythmogenic focus or pathway with cardiopulmonary bypass| 28.92| 48.07| $1,600
33254| Operative tissue ablation and reconstruction of atria, limited (e.g., modified Maze procedure)| 23.71| 40.21| $1,338
33255| Operative tissue ablation and reconstruction of atria, extensive (e.g., Maze procedure); without cardiopulmonary bypass| 29.04| 47.73| $1,589
33256| Operative tissue ablation and reconstruction of atria, extensive (e.g., Maze procedure); with cardiopulmonary bypass| 34.90| 56.51| $1,881
+33257| Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), limited (e.g., modified Maze procedure)| 9.63| 17.25| $574
+33258| Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (e.g., Maze procedure); without cardiopulmonary bypass| 11.00| 19.16| $638
+33259| Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (e.g., Maze procedure); with cardiopulmonary bypass| 14.14| 25.06| $834
33265| Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (e.g., modified Maze procedure); without cardiopulmonary bypass| 23.71| 40.18| $1,337
33266| Endoscopy, surgical; operative tissue ablation and reconstruction of atria, extensive (e.g., Maze procedure); without cardiopulmonary bypass| 33.04| 54.20| $1,804
Mitral Valve Surgery
33420| Valvotomy mitral valve; closed heart| 25.79| 42.63| $1,419
33422| Valvotomy mitral valve; open heart, with cardiopulmonary bypass| 29.73| 48.85| $1,626
33425| Valvuloplasty, mitral valve, with cardiopulmonary bypass| 49.96| 80.23| $2,671
33426| Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring| 43.28| 70.08| $2,333
33427| Valvuloplasty, mitral valve, with cardiopulmonary bypass; radical reconstruction, with or without ring| 44.83| 71.66| $2,385
33430| Replacement, mitral valve, with cardiopulmonary bypass| 50.93| 82.37| $2,742
Aortic Valve Surgery
33390| Valvuloplasty, aortic valve, open, with cardiopulmonary bypass; simple

(i.e., valvotomy, debridement, debulking, and/or simple commissural resuspension)

| 35.00| 56.48| $1,880
33391| Valvuloplasty, aortic valve, open, with cardiopulmonary bypass; complex

(e.g., leaflet extension, leaflet resection, leaflet reconstruction, or annuloplasty)

| 41.50| 66.94| $2,228
33405| Replacement, aortic valve, open, with cardiopulmonary bypass; with prosthetic valve other than homograft or stentless valve| 41.32| 66.76| $2,222
33406| Replacement, aortic valve, open, with cardiopulmonary bypass with allograft valve (freehand)| 52.68| 84.81| $2,823
33410| Replacement, aortic valve, open, with cardiopulmonary bypass with stentless tissue valve| 46.41| 74.68| $2,486
33411| Replacement, aortic valve; with aortic annulus enlargement, noncoronary sinus| 62.07| 98.40| $3,276
33412| Replacement, aortic valve with transventricular aortic annulus enlargement (Konno procedure)| 59.00| 91.94| $3,060
33413| Replacement, aortic valve; by translocation of autologous pulmonary valve with allograft replacement of pulmonary valve (Ross procedure)| 59.87| 94.24| $3,137
CPT*| Description| CY 2024

Physician Work Relative Value Units (RVUs)***

| CY 2024

Physician Total RVU

| CY 2024

National Payment Rate §

---|---|---|---|---
CABG
33533| Coronary artery bypass, using arterial graft(s); single arterial graft| 33.75| 55.09| $1,834
33534| Coronary artery bypass, using arterial graft(s); 2 arterial grafts| 39.88| 64.69| $2,153
33535| Coronary artery bypass, using arterial graft(s); 3 arterial grafts| 44.75| 71.87| $2,392
33536| Coronary artery bypass, using arterial graft(s); 4 or more arterial grafts| 48.43| 77.44| $2,577
Surgical LAAM and Select Imaging Studies
33267| Exclusion of left atrial appendage, open, any method| 18.50| 30.80| $1,025
+33268| Exclusion of left atrial appendage, concomitant, any method †| 2.50| 3.79| $126
33269| Exclusion of left atrial appendage, thoracoscopic, any method| 14.31| 24.50| $816
93312.26| Transesophageal echocardiogram; complete| 2.30| 3.11| $104
+93662.26| Intracardiac echocardiography during therapeutic/diagnostic intervention| 1.44| 2.05| $68
Electrophysiology Cardiac Ablation, Percutaneous LAAM and Select Imaging Studies
33340| Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement, left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation| 14.00| 22.84| $760
33999| Unlisted procedure, cardiac surgery| At payer discretion
93312.26| Transesophageal echocardiogram; complete| 2.30| 3.11| $104
+93462| Left heart catheterization by transseptal puncture through intact septum or by transapical puncture| 3.73| 6.06| $202
93600.26| Bundle of His recording| 2.12| 3.38| $113
93602.26| Intracardiac recording| 2.12| 3.32| $111
93603.26| Right ventricular pacing and recording| 2.12| 3.32| $111
+93613| Intracardiac EP 3-dimensional mapping| 5.23| 8.52| $284
93621.26| With left atrial pacing and recording from coronary sinus or left atrium| 1.50| 2.39| $80
93622.26| With left ventricular pacing and recording| 3.10| 4.93| $164
93631.26| Intra-operative epicardial and endocardial pacing and mapping to localize the site of tachycardia or zone of slow conduction for surgical correction| 7.59| 11.49| $382
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| 15.00| 24.42| $813
93654| 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| 18.10| 29.42| $979
+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| 5.50| 8.95| $298
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| 17.00| 27.69| $922
+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| 5.50| 8.96| $298
+93662.26| Intracardiac echocardiography during therapeutic/diagnostic intervention| 1.44| 2.05| $68

†Atrial appendage ligation, plication, or AtriClip is included in mitral valve and Maze procedures and should not be reported separately when performed in the same session as these procedures. §The facility payment is the physician’s professional fee in a facility setting. Average national rates are unadjusted by Geography Practice Cost Index. Payment rates reflect a conversion factor of $33.2875 (effective 3/15/2024) multiplied by the total relative value units (RVUs). +Indicates a secondary add-on procedure code to be listed with primary procedure code.

Limited operative ablation: Surgical isolation of triggers of supraventricular dysrhythmias by operative ablation that isolates the pulmonary veins or other anatomically defined triggers in the left or right atrium.

Extensive operative ablation : Services in limited ablation definition and additional ablation of atrial tissue to eliminate supraventricular dysrhythmias. This must include operative ablation that involves either the right atrium, the atrial septum or left atrium in continuity with the atrioventricular annulus.

Table 2. Endocardial Ablation Grid

 | SVT ABLATION (93653)| VT ABLATION (93654)| AF ABLATION (93656)
---|---|---|---
Procedure/Services Included with Ablations| Inherent| Bundled| Not Bundled; sometimes performed| Inherent| Bundled| Not Bundled; sometimes performed| Inherent| Bundled| Not Bundled; sometimes performed
Insert/reposition multiple catheters| X|  |  | X|  |  | X|  |
Transseptal catheterization(s) (93462)|  |  | X|  |  | X| X|  |
Induction or attempted induction of arrhythmia with right atrial pacing and recording| X|  |  | X|  |  |  | X|
Intracardiac ablation of arrhythmia| X|  |  | X|  |  | X|  |
SVT ablation| X|  |  |  |  |  |  |  |
VT ablation|  |  |  | X|  |  |  |  |
AF ablation|  |  |  |  |  |  | X|  |
Intracardiac 3D mapping (93613)|  | X|  |  | X|  |  | X|
Right ventricular pacing and recording (93603)|  | X|  |  | X|  |  | X|
Left atrial pacing and recording from

coronary sinus or left atrium (93621)

|  |

X

|  |  |

X

|  |  |

X

|
His bundle recording (93600)|  | X|  |  | X|  |  | X|
Intracardiac recording (93602)| X|  |  | X|  |  | X|  |
Left ventricular pacing and recording (93622)|  |  |  |  | X|  |  |  |
Intracardiac echocardiography (93662)|  |  | X|  |  | X|  | X|
Additional linear or focal intracardiac catheter ablation of the left or right atrium (93657)|  |  |  |  | | | | | X
Intracardiac catheter ablation of a discrete mechanism of arrhythmia which

is distinct from the primary ablated mechanism (93655)

|  |  | X|  |  | X| |  | X

Table 3. Inpatient Facility Coding and Reimbursement

The site of service depends on the patient’s chief complaint, clinical presentation and is solely determined by the admitting physician. The ICD-10-CM (Internal Classification of Disease, Tenth Revision, Clinical Modification) Diagnosis Code(s) and primary ICD-10 PCS (procedure coding system(s)) determine the MS-DRG (Medicare Severity Diagnosis Related Group)

FY 2024 FY 2024                     FY 2024

Weighting Arithmetic               Inpatient System          Mean LOS Prospective

MS-DRG** Description Payment System

Cardiac Valve
212| Concomitant aortic and mitral valve procedures (three procedures must be met)| 10.77| 15.7| $75,412
216| Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with MCC| 9.71| 14.5| $67,953
217| Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with CC| 6.37| 7.1| $44,567
218| Cardiac valve and other major cardiothoracic procedures with cardiac catheterization without CC/MCC| 5.70| 3.1| $39,886
219| Cardiac valve and other major cardiothoracic procedures without cardiac catheterization with MCC| 7.71| 10.7| $53,991
220| Cardiac valve and other major cardiothoracic procedures without cardiac catheterization with CC| 5.24| 6.3| $36,721
221| Cardiac valve and other major cardiothoracic procedures without cardiac catheterization without CC/MCC| 4.65| 4.0| $32,548
CABG
231| Coronary bypass with PTCA with MCC| 8.12| 12.0| $56,819
232| Coronary bypass with PTCA without MCC| 5.95| 8.3| $41,650
233| Coronary bypass with cardiac catheterization or open ablation with MCC| 7.80| 12.8| $54,610
234| Coronary bypass with cardiac catheterization or open ablation without MCC| 5.20| 8.6| $36,394
235| Coronary bypass without cardiac catheterization with MCC| 5.88| 9.5| $41,174
236| Coronary bypass without cardiac catheterization without MCC| 4.04| 6.3| $28,295
Cardiac Surgical Ablation
228| Other cardiothoracic procedures with MCC| 5.04| 9.1| $35,279
229| Other cardiothoracic procedures without MCC| 3.18| 3.4| $22,262
Percutaneous Catheter Ablation
273| Percutaneous intracardiac procedures with MCC| 3.90| 5.5| $27,285
274| Percutaneous intracardiac procedures without MCC| 3.24| 1.5| $22,691

CC = comorbidity or complication, MCC = major complication or comorbidity, w/o = without, PTCA = percutaneous transluminal coronary angioplasty.
**Source: FY 2024 Medicare inpatient rates based upon Final Rule release. Conversion Factor = $7,001.60

Table 4. Outpatient Hospital Reimbursement

CPT| Procedure Description| CY 2024

Comprehensive APC*

| CY 2024

APC Title

| CY 2024

Medicare National Standardized APC Payment (HOPPS)

---|---|---|---|---
Percutaneous Catheter Ablation
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| 5213| Level 3 EP Procedure| $22,653
93654| 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
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

Table 5. Common ICD-10 codes used during LAAM, cardiac surgery and EP

ablation procedures

percutaneous
02L74DK| Occlusion of left atrial appendage with intraluminal device, percutaneous endoscopic
02L73ZK| Occlusion of left atrial appendage, percutaneous
02L74ZK| Occlusion of left atrial appendage, percutaneous endoscopic
02L70CK| Occlusion of left atrial appendage with extraluminal device, open
02L73CK| Occlusion of left atrial appendage with extraluminal device, percutaneous
02L74CK| Occlusion of left atrial appendage with extraluminal device, percutaneous endoscopic

Open approach: An open approach is defined as cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure.
Percutaneous approach: A procedure performed via a percutaneous approach (character value 3) is one in which there is entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure.
Percutaneous endoscopic approach: Percutaneous endoscopic approach (character value 4) is defined as entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure.

Peer-Reviewed Evidence

Clinical evidence in support of surgical cardiac ablation and left atrial appendage surgical closure, includes, but is not limited to, the following peer-reviewed publications. Citations are available upon request.

Cardiac surgical ablation with/without concomitant cardiac surgery (CABG, MVR, AVR)

Ad, N. et al. (2012). Surgical ablation of atrial fibrillation trends and outcomes in North America. J Thorac Cardiovasc Surg, 144(5):1051-60.

Amin, A.K. et al. (2022). Healthcare Utilization and Costs in Patients with Atrial Fibrillation before and after Hybrid Ablation. Journal of Atrial Fibrillation and EP , 15(6).

Badhwar, V. et al. (2017). The Society of Thoracic Surgeons 2017 clinical practice guidelines for the surgical treatment of atrial fibrillation. Ann Thorac Surg, 103(1):329-41.

Badhwar, V. et al. (2017). Surgical ablation of atrial fibrillation in the United States: Trends and propensity matched outcomes. Ann Thorac Surg, 104(2):493-500.

DeLurgio, D.B. et al. (2020). Hybrid Convergent Procedure for the Treatment of Persistent and Long-Standing Persistent Atrial Fibrillation: Results of CONVERGE Clinical
Trial. Circ Arrhythm Electrophysiol, 13(12):e009288

Doll, N. et al. (2023). Efficacy and safety of hybrid epicardial and endocardial ablation versus endocardial ablation in patients with persistent and longstanding persistent atrial fibrillation: A randomised, controlled trial. EClinicalMedicine, 61(102052).

Gillinov, A.M. et al. (2015). Surgical ablation of atrial fibrillation during mitral-valve surgery. N Engl J Med, 372(15):1399-409.

Musharbash, F.N. et al. (2018). Performance of the Cox-maze IV procedure is associated with improved long-term survival in patients with atrial fibrillation undergoing cardiac surgery. J Thorac Cardiovasc Surg, 155(1):159-70. Philpott, J.M. et al. (2015). The ABLATE trial: safety and efficacy of Cox Maze-IV using a bipolar radiofrequency ablation system. Ann Thorac Surg, 100(5):1541-8. Rankin J.S. et al. (2020). Surgical ablation of atrial fibrillation concomitant to coronary-artery bypass grafting provides cost-effective mortality reduction. J Thorac Cardiovasc Surg, 160(3): 675-86.

Concomitant cardiac surgery with either (CABG, MVR, AVR) and surgical left atrial appendage management

Caliskan, E. et al. (2018). Epicardial left atrial appendage AtriClip occlusion reduces the incidence of stroke in patients with atrial fibrillation undergoing cardiac surgery. Europace, 20(7):e105-14.

Elbadawi, A. et al. (2017). Impact of left atrial appendage exclusion on cardiovascular outcomes in patients with  atrial fibrillation undergoing coronary artery bypassgrafting (From the National Inpatient Sample Database). Am J Cardiol, 120(6):953-8. Friedman, D.J. et al. (2018). Association between left atrial appendage occlusion and readmission for thromboembolism among patients with atrial fibrillation undergoing concomitant cardiac surgery. JAMA, 23;319(4):365-74.

Mehaffey, J.H., et al. (2023). Surgical ablation of atrial fibrillation is associated with improved survival compared with appendage obliteration alone: An analysis of 100,000 Medicare beneficiaries. J Thorac Cardiovasc Surg, Epub ahead of print. Park-Hansen, J. et al. (2018). Adding left atrial appendage closure to open heart surgery provides protection from ischemic brain injury six years after surgery independently of atrial fibrillation history: the LAACS randomized study. J Cardiothorac Surg, 23;13(1):53. Soltesz, E.G. et al. (2021). Improved outcomes in CABG patients with atrial fibrillation associated with surgical  leftatrial appendage exclusion. J Card Surg, 36(4):1201-8.
Whitlock, R.P. et al. (2021). LAAOS III Investigators. Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke. N Engl J Med, 384(22):2081-91.

Additional Sources

CPT® is a registered trademark of the American Medical Association

*Source: American Medical Association. CPT 2024 Professional Edition. The facility payment is the physician’s professional fee in a facility setting. Average national rates are unadjusted by Geography Practice Cost Index. Payment rates reflect a conversion factor of $33.2875 (effective 03/15/2024).

CC = comorbidity or complication, MCC = major complication or comorbidity, w/o = without, PTCA = percutaneous transluminal coronary angioplasty.

**Source: FY 2024 Medicare inpatient rates based upon Final Rule release. Conversion Factor = $7,001.60 CY 2024 Medicare outpatient rates based upon Final Rule release. FY24 AMA ICD-10 PCS codebook

Sample/No Cost device: If you received a device as a sample or at no cost, unrelated to a recall, please notify your reimbursement staff. The hospital procedure claim could require additional modifiers or supplemental information to properly account for the reduction in sale price.

Please refer to the Medicare claims manual for the most up to date guidance, the following link is provided: https://www.cms.gov/Regulations-and Guidance/Guidance/Manuals/Downloads/clm104c04.pdf

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Mason, Ohio 45040 USA
www.AtriCure.com

For questions and/or additional information, please contact AtriCure’s health policy helpline at 1 303-845-2027 (phone or text) or via email at JGarfield@InSearch-Solutions.com

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