Atrial fibrillation (AF) ablation—CPT 93656—is one of the most complex electrophysiology (EP) procedures in cardiology coding. Because AF ablation bundles multiple components (diagnostic EP study, mapping, intracardiac signals, transseptal puncture, pacing maneuvers), coders must understand what is included, what can be billed separately, and what documentation supports the code.
Incorrect billing of 93656 is a top target for commercial payer audits due to high reimbursement and variable documentation quality.
This guide explains exactly what CPT 93656 includes, when add-on codes apply, what documentation must be present, common denial triggers, and payer considerations. It is written to be purely informational and practical for real-world clinical billing.
What CPT 93656 Covers
CPT 93656 describes:
“Comprehensive electrophysiologic evaluation including pulmonary vein isolation (PVI) for treatment of atrial fibrillation by ablation.”
This code includes all of the following when performed:
- Complete EP study
- Mapping inside the left and right atrium
- Intracardiac electrograms
- Pacing and stimulation maneuvers
- Transseptal puncture
- Pulmonary vein isolation (PVI)
- Left atrial ablation for AF
- All standard imaging guidance is required to complete the procedure
Because CPT 93656 is comprehensive, many services often attempted separately are in fact bundled.
When Add-On Codes May Be Billed
Although AF ablation is comprehensive, some add-on codes can be billed when medically justified and documented.
Intracardiac Echocardiography (ICE) – CPT 93662
Billable when used for:
- Left atrial visualization
- Transseptal puncture imaging
- Thrombus evaluation
- Catheter guidance
Must include interpretation in the report.
Additional Linear Lesion Ablation – CPT 93657
Used for add-on ablation lines performed AFTER AF ablation/PVI.
Examples:
- Roof line
- Mitral isthmus line
- Posterior wall isolation (when added separately beyond PVI)
Rules:
- Must be distinct from the PVI
- Must include arrhythmia mechanism or substrate explanation
- May be billed more than once per session when separate lesions are created
His Bundle or AV Node Ablation
Not part of AF ablation.
If performed for AV nodal ablation after failed rhythm control → separate code (e.g., 93650).
Cardioversion
If performed before the ablation to convert AF → bundled.
If performed after ablation solely to evaluate efficacy → bundled.
If performed for persistent arrhythmia unrelated to ablation, → may be separately reportable (rare).
Services Bundled Into 93656
Do NOT bill the following separately during AF ablation:
- Comprehensive EP study (93619/93620)
- 3D mapping (93613)
- Left atrial pacing (93621)
- Transseptal puncture (93462)
- Signal recording & intracardiac electrograms
- Fluoroscopy
- Pulmonary vein mapping
NCCI edits list these as Column 2 (component) codes, meaning they are considered inherent to 93656.
Documentation Requirements for CPT 93656
A complete AF ablation note must include the following:
1. Indication & Medical Necessity
- AF type: paroxysmal, persistent, longstanding persistent
- Symptom burden
- Failure or intolerance of antiarrhythmic drugs
- Prior ablations or failed rhythm control therapy
2. Comprehensive EP Study Elements
Document:
- Atrial and ventricular recording
- Pacing maneuvers
- Induction of arrhythmias
- Atrial and ventricular activation sequences
- Electrode catheter positions
3. Mapping
Document:
- Technique used (anatomic, electroanatomic)
- Chamber(s) mapped
- Regions with abnormal signals
- Voltage map findings
4. Transseptal Access
Should include:
- Use of ICE or fluoroscopy
- Sheath and needle technique
- Successful entry into the left atrium
5. Ablation Details
Must include:
- Pulmonary vein isolation achieved (entrance + exit block)
- Energy type (RF, cryo)
- Duration and power
- Any additional linear lesions
- If CPT 93657 is billed → each additional lesion documented separately
6. Post-Ablation Evaluation
Document:
- Rhythm outcome
- Arrhythmia inducibility testing
- Absence/presence of complications
7. Imaging Services
If billing 93662 (ICE), document actual interpretation and imaging findings.
Payer Considerations
Medicare
CPT 93656 is widely covered for AF that meets criteria:
- Symptomatic AF
- Failure of medical therapy
- Appropriate pre-procedural imaging and assessment
Add-on 93657 is commonly audited.
Commercial Payers
Often require:
- Prior authorization
- Documentation of failed antiarrhythmic drug trials
- Recent ECG or Holter documenting AF type
- Shared decision-making documentation
Medicare Advantage
Tends to:
- Scrutinize 93657 units
- Require strong proof of the necessity of additional lesions necessity
- Deny ICE bills lacking interpretation
Common Denials & How to Prevent Them
1. Insufficient documentation of PVI
Many denials occur when the note does NOT clearly document:
- Entrance block
- Exit block
- Confirmation of isolation
2. Unsupported 93657
93657 must show:
- A lesion beyond PVI
- Purpose of the lesion
- Distinct ablation lines
3. ICE billed without interpretation
“ICE used to guide procedure” → denied
Must describe:
- Visualization
- Findings
- Guidance purpose
4. Missing drug failure documentation
Commercial payers deny when AAD failure/side effects are not documented.
5. Coding EP study components separately
Cannot bill 93620, 93621, 93613 with 93656.
6. Misuse of modifiers
Most AF ablation claims do not require modifier 59.
Modifiers should only be used for separately identifiable additional ablations or unrelated cardioversion.
AF Ablation Billing Scenarios
Scenario 1 – PVI only
Documentation confirms:
- AF ablation with isolation of all veins
- → Bill 93656
Scenario 2 – PVI + roof line
Documentation confirms an additional linear lesion
→ Bill 93656 + 93657
Scenario 3 – PVI + posterior wall + mitral isthmus
→ Bill 93656 + 93657 (x2)
Each lesion must be documented separately.
Scenario 4 – Cardioversion before ablation
Used to restore rhythm for mapping → bundled.
Scenario 5 – ICE used with imaging interpretation
→ Bill 93656 + 93662
Audit Risk Areas
Auditors focus on:
- Whether PVI was achieved
- Whether 93657 was justified
- Whether ICE had an interpretation
- Whether patient met clinical criteria
- Whether documentation describes mapping
- Whether catheter positioning was clearly described
Strong, detailed documentation reduces audit exposure.
Coding Summary
Code Description Billable With 93656?
93656 AF ablation with PVI Yes (primary)
93657 Additional LA ablation Yes
93662 Intracardiac echo Yes
93613 3D mapping Bundled
93620 EP study Bundled
93462 Transseptal puncture Bundled
92960 Cardioversion : Usually bundled
93650 AV node ablation Separate if medically distinct
| Code | Description | Billable With 93656? |
| 93656 | AF ablation with PVI | Yes (primary) |
| 93657 | Additional LA ablation | Yes |
| 93662 | Intracardiac echo | Yes |
| 93613 | 3D mapping | Bundled |
| 93620 | EP study | Bundled |
| 93462 | Transseptal puncture | Bundled |
| 92960 | Cardioversion | Usually bundled |
| 93650 | AV node ablation | Separate if medically distinct |
Tips for Clean Claims
- Ensure the report explicitly states “all pulmonary veins isolated.”
- Add a line for the entrance and exit block
- Clearly label each additional lesion (93657) as its own subsection
- Include ICE interpretation for 93662
- Make sure the indication states drug failure or intolerance
- Include pre-procedure rhythm documentation
- Avoid billing bundled codes (mapping, stim, pacing)
- Verify prior authorization for commercial plans
Final Note
Accurate billing of atrial fibrillation ablation requires understanding what CPT 93656 includes, how add-on codes apply, and which components are bundled automatically. Detailed, structured documentation is the key to avoiding denials, especially for add-on lesion codes and intracardiac echo. Many practices improve compliance by standardizing EP ablation report templates and reviewing claims pre-submission. Expert RCM teams, such as Global Tech Billing LLC, often help clinicians maintain accuracy in this highly audited service line.
FAQs
1. What does CPT 93656 include?
It includes a full EP study, transseptal puncture, PVI, mapping, pacing, and intracardiac recordings.
2. When can CPT 93657 be billed?
When an additional left atrial lesion beyond PVI is performed and fully documented.
3. Is 3D mapping separately billable with AF ablation?
No, it is bundled into CPT 93656.
4. When is intracardiac echocardiography (ICE) billable?
When interpretation is documented and clinical need is clear.
5. Are cardioversions billable during ablation?
Only if unrelated to the ablation procedure; most are bundled.
6. What is the most common denial for AF ablation?
Lack of documentation proving successful PVI.
7. Does the EP study code 93620 bill with 93656?
No, it is bundled.
8. Do payers require drug therapy failure?
Yes, most require documented antiarrhythmic drug failure or intolerance.
