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Documentation in CPT 93657

Date: Jun 28, 2021

Question:

The description for code 93657 is as follows: "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)".

Is it absolutely imperative that the provider explicitly document that atrial fibrillation remained or complex fractionated atrial electrograms were present following pulmonary venous isolation in order to report this CPT code? Or is documented ablation of the atrial wall itself sufficient enough to support 93657, devoid of mention of remaining Afib/CFAEs?

Question ID : 15630
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