Atrial Fibrillation Ablation (Pulmonary Vein Isolation)

CPT 93656
Approach Endovascular
Add-on / Variant CPTs
  • 93657 — Additional ablation (LA posterior wall / roof / complex fractionated electrograms)
Preoperative Diagnosis:

Symptomatic [paroxysmal / persistent / long-standing persistent] atrial fibrillation, refractory to [antiarrhythmic medication / cardioversion]

Postoperative Diagnosis:

Same

Procedure Performed:

Catheter ablation with pulmonary vein isolation (PVI) [and posterior wall isolation], [radiofrequency / cryoablation / pulsed field ablation]

Attending Surgeon:

[Attending name], MD/DO [EP]

First Assistant:

[EP nurse/tech]

Anesthesia:

General endotracheal [/ deep sedation]

Indications:

The patient is a [age]-year-old [male/female] with [paroxysmal / persistent] atrial fibrillation with symptomatic [palpitations / dyspnea / functional limitation] refractory to [antiarrhythmic drug X] with [X] cardioversions. CHA₂DS₂-VASc score [X]. Left atrial size [X] mm. PVI was recommended. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

Transseptal access was obtained. Three-dimensional electroanatomic map of the left atrium was created. All four pulmonary veins were identified and isolated. Entry and exit block were confirmed. [The posterior wall was isolated as an additional ablation lesion.] [CTI ablation was performed for concomitant atrial flutter.] No pulmonary vein reconnection was demonstrated on repeat mapping.

Description of Procedure:

The patient was positioned supine. Bilateral femoral venous access was obtained. A [10-Fr] quadripolar catheter was placed in the coronary sinus via the right femoral vein. Transseptal puncture was performed under [ICE / TEE / fluoroscopic] guidance. Entry into the left atrium confirmed.

A [3-D electroanatomic mapping system (CARTO / EnSite)] was used to create a left atrial geometry. The four pulmonary veins were identified: left superior (LSPV), left inferior (LIPV), right superior (RSPV), and right inferior (RIPV).

[RF ABLATION:]
A [contact-force sensing ablation catheter (ThermoCool SmartTouch)] was used. Ablation was performed at [30–35 W] with target contact force [10–30 g] circumferentially around the ipsilateral pulmonary vein pairs. Point-by-point ablation lesions were delivered to create continuous encirclement. Entry and exit block were confirmed for each vein pair.

[CRYO ABLATION:]
A [28-mm] Arctic Front Advance cryoballoon was advanced to each pulmonary vein ostium under fluoroscopic guidance. Occlusion was confirmed. Freeze cycles of [3–4 minutes] were delivered at temperatures of [−45 to −55°C]. Isolation was confirmed with a spiral mapping catheter.

[Additional ablation:] [Posterior wall isolation / CTI ablation / cavotricuspid isthmus / roof line] was performed.

Post-ablation mapping confirmed all pulmonary veins isolated with no reconnection. Phrenic nerve pacing confirmed intact nerve function. [Cardioversion was performed to restore sinus rhythm.] Sheaths were removed. Manual compression was applied to the femoral access sites until hemostasis.

Complications:

None

Specimens:

None

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

The patient was monitored for [4–6 hours] post-procedure. ECG confirmed [sinus rhythm / AF continues (repeat cardioversion scheduled)]. Anticoagulation was continued. Antiarrhythmic therapy was continued for [3 months] post-ablation (blanking period). Follow-up with rhythm monitoring (Holter / implantable loop recorder) was planned at [3 months].

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: *** AF, paroxysmal/persistent, refractory to ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Catheter ablation, PVI [+ posterior wall], RF/cryo/PFA
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General/deep sedation

INDICATIONS: .PTAGE-year-old .PTSEX with *** AF, refractory to ***, CHA2DS2-VASc ***, LA *** mm. Consent obtained.

FINDINGS: Transseptal access. LA geometry created. All 4 PVs isolated. Entry/exit block confirmed. [PW isolation.] [CTI ablation.] No reconnection.

PROCEDURE:
Supine. Bilateral femoral venous access. CS catheter. Transseptal under ICE/TEE/fluoro — LA confirmed. LA geometry (CARTO/EnSite). PVs mapped. [RF: contact-force catheter, 30–35 W, CF 10–30 g, circumferential LSPV/LIPV, RSPV/RIPV. Entry/exit block confirmed.] [Cryo: 28 mm balloon, each vein ostium, occlusion confirmed, *** min freeze, isolation confirmed spiral catheter.] [Additional: ***.] Post-ablation: all PVs isolated. Phrenic nerve intact. [DCCV → sinus.] Sheaths removed, compression until hemostatic.

EBL: Minimal
COMPLICATIONS: None
DISPOSITION: Monitored *** hours. Anticoagulation continued. Blanking period *** months. Rhythm monitoring *** months.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Surgical Maze (Concomitant with Cardiac Surgery)

Concomitant surgical ablation (modified Cox-Maze IV procedure) was performed at the time of [mitral valve surgery / CABG]. Bipolar radiofrequency clamps were used to create the Maze lesion set: bilateral pulmonary vein isolation, posterior wall isolation, roof line, mitral isthmus line, right atrial lesions (SVC to IVC isthmus), and left atrial appendage ligation [/ excision]. Left atrial appendage was [ligated / stapled] for stroke risk reduction. The surgical Maze is preferred over catheter ablation for patients with long-standing persistent AF undergoing cardiac surgery, with superior long-term freedom from AF.

Charting Tips
  • Document entry and exit block confirmation for each pulmonary vein. Entry block (inability to capture tissue from within the vein outside the ablation circle) and exit block (inability to drive the left atrium from within the vein) confirm bidirectional conduction block. Document each vein individually.
  • Document phrenic nerve monitoring. The right phrenic nerve runs adjacent to the RSPV and the left phrenic nerve adjacent to the left pulmonary veins. Cryoablation and PFA carry phrenic nerve injury risk. Document that 'phrenic nerve pacing was performed during ablation and nerve function was confirmed intact.'
  • Document anticoagulation continuation post-procedure. Uninterrupted oral anticoagulation is recommended for at least 2–3 months post-ablation regardless of apparent sinus rhythm. Document the specific anticoagulant, dose, and duration plan. Stopping anticoagulation too early after AF ablation is a common cause of post-procedural stroke.
Billing Tips
  • Bill 93656 for comprehensive electrophysiologic evaluation with ablation for atrial fibrillation (16.58 wRVU, 0-day global). This includes all mapping, testing, and ablation performed during the same session.
  • Bill 93657 as an add-on code for each additional linear or focal ablation of the left or right atrium (+5.36 wRVU). Document each additional ablation set performed beyond the primary pulmonary vein isolation.
  • 0-day global period: post-procedure monitoring, anticoagulation management, and follow-up cardioversions are not bundled. Office visits and rhythm monitoring can be billed separately.
  • Diagnostic electrophysiology study (93619, 93620) is bundled when performed as part of an ablation session. Do not bill the diagnostic EP study in addition to 93656 for the same encounter.
  • The surgical maze procedure (performed at the time of open cardiac surgery) uses different codes (33254-33259) and is not the same as catheter-based ablation. These code families should not be confused.