CPT code 93580: Percutaneous transcatheter closure of interatrial defect

Key Takeaways

CPT Code 93580 describes percutaneous transcatheter closure of a congenital interatrial communication (Fontan fenestration, ASD) with implant.

Valid paired ICD-10 diagnoses include Q21.1 (atrial septal defect) for congenital closures; some payers also accept I51.0 (acquired cardiac septal defect) and I23.1 (ASD post-MI).

NCCI edits bundle 93580 with open septal defect repair codes; billing 93580 alongside 93531 (right and left heart cath) triggers an NCCI procedure-to-procedure (PTP) edit.

Pabau’s claims management software helps cardiology billing teams track prior authorization status, attach supporting documentation, and reduce claim denials for complex structural heart codes.

This reference covers the official CPT Code 93580 descriptor, applicable ICD-10 diagnosis codes, modifier rules, NCCI edit exposure, payer-specific coverage policies, and 2025-2026 Medicare reimbursement data for interventional cardiologists and hospital billing departments.

CPT Code 93580: Procedure definition and clinical description

CPT Code 93580 is maintained by the American Medical Association as part of the Repair Procedures of Structural Heart Defect subsection (93580-93582) within the Medicine section of the CPT code set.

The official descriptor reads: Percutaneous transcatheter closure of congenital interatrial communication (i.e., Fontan fenestration, atrial septal defect) with implant.

Three anatomical targets are commonly reported under 93580:

• Atrial septal defect (ASD): A hole in the wall between the heart’s upper chambers, present from birth. The most common structural variant coded to 93580.
• Patent foramen ovale (PFO): A flap-like opening in the atrial septum that failed to close after birth. Multiple payer policies explicitly include PFO closure under 93580.
• Fontan fenestration: A surgically created communication between the systemic venous pathway and the pulmonary circuit in Fontan palliation patients. Percutaneous closure of this fenestration maps to 93580.

The procedure involves advancing a catheter via venous access (typically transfemoral), crossing the interatrial septum, and deploying a septal occluder device under fluoroscopic and echocardiographic guidance. No thoracotomy or cardiopulmonary bypass is required.

CPT 93580 is a global code covering the entire interventional episode: access, catheter manipulation, septal crossing, device deployment, and imaging confirmation. Services inherently included in the global procedure are not separately reportable. For CPT coding resources for specialty practices, understanding which services are bundled versus separately billable is the first step in avoiding denials.

Related structural heart defect CPT codes: 93581 and 93582

CPT Code 93580 belongs to a three-code range. Each code describes a specific anatomical target:

CPT Code 93580 and 93581 cannot be reported together for the same session when both an ASD and a VSD are closed simultaneously. The AMA CPT guidance and NCCI edits treat this as unbundling. Use the code for the primary defect addressed. If a congenital VSD is the target, report 93581, not 93580.

ICD-10-CM diagnosis codes that support 93580 medical necessity

Every claim for 93580 requires a paired ICD-10-CM diagnosis code that establishes medical necessity. Payers match the diagnosis to their coverage criteria before adjudication. The table below lists the primary codes verified against current payer policies.

The congenital vs. acquired coding distinction carries real reimbursement implications. CPT Code 93580 explicitly references congenital interatrial communication. Pairing it with I51.0 (acquired) or I23.1 (post-MI) may trigger a coverage denial from payers who interpret 93580 as congenital-only.

Some payers, including Cap Blue Cross, have listed I51.0 and I23.1 in their covered diagnosis tables; others have not. Verify the specific payer’s code coverage table before submitting. The same principle applies across specialty coding: diagnosis-procedure alignment determines coverage.

Modifiers applicable to CPT Code 93580

Modifier selection for 93580 depends on billing context: professional vs. technical component, bilateral procedures, and repeat sessions.

• Modifier 26 (Professional component): Applied when the physician performs and interprets the procedure but does not own the facility. Hospital-employed physicians billing globally for the institutional setting do not append modifier 26; the facility bills the technical component separately.
• Modifier TC (Technical component): Used by the facility or hospital outpatient department for the equipment, staff, and overhead costs of the procedure when split billing applies.
• Modifier 59 (Distinct procedural service): May be required when 93580 is billed on the same date as another procedure that shares an NCCI edit. Modifier 59 overrides the edit only when the services are genuinely separate and distinct and when the edit allows an override. Not all 93580-related edits permit a modifier override (see NCCI edits section below).
• Modifier 22 (Increased procedural services): Applicable when the procedure is substantially more difficult than typically required (for example, complex anatomy, multiple devices, or failed initial deployment). Requires detailed documentation in the operative report explaining the added complexity and time.
• Modifier 76 (Repeat procedure by same physician): Used if a second closure is required in the same session or a subsequent session due to device embolization or residual defect.

Medicare does not allow modifier TC on 93580 when billed by a physician performing the service in a facility setting. The global fee for 93580 on the Medicare Physician Fee Schedule reflects the professional component only when reported in a facility; the facility bills the technical component through the outpatient prospective payment system (OPPS). Use the correct place of service code (POS 21 for inpatient, POS 22 for outpatient hospital) to ensure the correct RVU calculation applies.

NCCI edits and bundling rules for 93580

The National Correct Coding Initiative (NCCI) establishes which procedure codes cannot be billed together without a valid override modifier. For 93580, the most clinically significant edit involves right and left heart catheterization.

93580 and right and left heart catheterization (93531)

Billing 93580 with 93531 (combined right heart catheterization and retrograde left heart catheterization, for congenital cardiac anomalies) triggers an NCCI procedure-to-procedure (PTP) edit at the hospital outpatient level. This edit reflects the fact that catheter placement and cardiac access are considered inherent to the closure procedure itself. The hospital cannot separately report the catheterization service when it is performed solely to facilitate the 93580 closure.

There is an important nuance here. If the right and left heart catheterization was performed for a distinct diagnostic purpose (for example, pre-procedure hemodynamic assessment requested independently of the closure planning), some payers may allow separate billing with modifier 59 on the catheterization code.

The operative report must clearly document that the catheterization served a distinct diagnostic purpose not integral to the closure. This is a high-audit area. See EHR integration for cardiology billing for how integrated documentation tools can help coders flag these distinctions in real time.

93580 and open septal defect repair codes

NCCI edits bundle CPT Code 93580 with open septal defect repair codes (including CPT 33641). A percutaneous transcatheter closure and an open surgical repair are mutually exclusive approaches. Reporting both in the same session signals an error or upcoding. Only report 93580 when the procedure is performed percutaneously without surgical access.

Intracardiac echocardiography (ICE) billing

Intracardiac echocardiography (ICE) guidance is commonly used during ASD and PFO closure. Whether ICE can be billed separately alongside 93580 depends on the payer and the operative report. Some payers treat ICE as inherent to 93580; others allow it as a separately reportable service when documented as a distinct diagnostic study.

Review the specific payer’s payment policies before reporting ICE codes alongside 93580. The CMS Physician Fee Schedule lookup tool allows verification of whether ICE codes carry an NCCI edit relationship with 93580 for the current fiscal year.

Reduce claim denials on complex cardiology procedures

Pabau's claims management tools help billing teams attach prior authorization documentation, track denial patterns, and resubmit structural heart procedure claims faster.

Book a demo

Payer coverage policies for 93580

Coverage criteria for 93580 vary meaningfully across major commercial payers. The procedure is generally covered for symptomatic ASD and PFO closure, but each payer imposes specific clinical criteria that must be met and documented. Billing teams managing medical practice scheduling and billing workflows across payers should maintain a payer-specific coverage matrix for 93580.

UnitedHealthcare (UHC)

UHC’s Provider Policy covers percutaneous PFO and ASD closure under 93580 when specific criteria are met. For PFO closure, UHC typically requires documentation of a prior cryptogenic stroke or TIA with evidence of right-to-left shunting and absence of another identifiable cause.

Device selection and operator experience requirements may also apply. Coverage criteria are updated periodically; verify against the current UHC commercial policy before submitting.

Aetna

Aetna’s Clinical Policy Bulletin on catheter-directed cardiac procedures addresses PFO and ASD closure. Aetna covers PFO closure via 93580 for secondary stroke prevention in patients meeting age thresholds and specific neurological criteria.

ASD closure is covered for hemodynamically significant defects. Investigational indications (such as PFO closure for migraine prevention) are not covered and will result in denial if submitted without appropriate documentation of a covered indication.

Blue Shield of California and Blue Cross

Blue Shield of California explicitly lists 93580 in its closure devices medical policy for PFO and ASD. Blue Cross (including Cap Blue Cross and Blue Cross MA) similarly covers 93580 with HCPCS code C1817 for the implantable closure device.

Cap Blue Cross additionally lists ICD-10-CM codes I23.1 and I51.0 as covered diagnoses alongside Q21.1, meaning acquired defect closures may be covered under specific circumstances. Confirm the current covered diagnosis list in the active policy before billing.

Carelon Medical Benefits Management

Carelon’s guidelines for catheter-based PFO closure were reaffirmed effective November 1, 2024. Carelon requires prior authorization for 93580 and mandates documentation of qualifying prior neurological events, echocardiographic confirmation of the defect, and compliance with patient selection criteria. The prior authorization process must be completed before the procedure date.

Documentation requirements for 93580 claims

Insufficient documentation is the leading cause of post-payment audit recoupment for structural heart procedure codes. Every 93580 claim should be supported by a complete operative report that captures the following elements.

• Procedure indication: Clinical rationale linking the specific defect (ASD, PFO, Fontan fenestration) to the closure. Include the diagnosis code and the clinical findings that establish medical necessity (for example, echocardiographic defect size, symptoms, or qualifying neurological events for PFO).
• Access and approach: Venous access site, catheter type, transseptal crossing technique, and fluoroscopic/echocardiographic guidance used.
• Device specification: Implant name, size, and lot number. HCPCS code C1817 is billed for the implantable closure device; the operative report must support its use.
• Hemodynamic data: Shunt calculations (Qp:Qs ratio), oxygen saturation measurements, and pressure data when performed. If a separate right and left heart catheterization was performed for a distinct diagnostic purpose, document this clearly and separately from the closure procedure notes.
• Imaging guidance confirmation: Whether fluoroscopy alone or combined ICE/TEE guidance was used. If ICE is billed separately, document it as a distinct service with its own interpretation note.
• Outcome and complications: Device deployment success, residual shunt assessment, and any complications or conversion to open surgery.

For hospital billing departments, maintaining HIPAA-compliant documentation practices that include structured operative report templates reduces audit exposure significantly. A HIPAA compliance checklist integrated into the pre-bill review process helps identify documentation gaps before submission. Cardiology practices using patient intake software can also capture pre-procedure indications and patient consent within the same record.

2025-2026 Medicare reimbursement for CPT Code 93580

Medicare reimbursement for 93580 is calculated using the Medicare Physician Fee Schedule (MPFS) relative value unit (RVU) system. Rates vary by geographic practice cost index (GPCI) and are updated annually on January 1. The figures below reflect national non-facility rates as a reference point; actual payment amounts depend on the provider’s location and Medicare Administrative Contractor (MAC) jurisdiction.

According to the CMS list of CPT/HCPCS codes, 93580 carries a significant RVU weighting consistent with a major invasive cardiac procedure. Use the FastRVU 2026 RVU lookup tool to retrieve current Work RVU, Practice Expense RVU, and Malpractice RVU values specific to your locality and place of service. The AAPC Codify platform at AAPC Codify CPT code lookup also provides current reimbursement benchmarks by payer type.

Key reimbursement considerations for 93580 billing teams:

• Facility vs. non-facility rates: The facility rate applies when the procedure is performed in a hospital outpatient department or ambulatory surgical center. The non-facility rate applies to office-based settings, which is rarely applicable for a structural heart intervention.
• HCPCS C1817 device billing: The implantable closure device is separately billed using HCPCS code C1817 (septal defect implant system, intracardiac). Facilities bill C1817 on the UB-04 claim form; the physician does not bill C1817 on the CMS-1500. Verify current status with your MAC, as pass-through payment status for specific devices changes annually.
• Prior authorization impact: Most commercial payers require prior authorization. Claims submitted without authorization are denied on receipt, not adjudicated. Track authorization expiration dates alongside procedure scheduling.
• Geographic adjustment: Medicare rates in high-cost localities (San Francisco, Manhattan, Boston) are materially higher than national averages. Use the CMS MPFS lookup tool or a fee schedule calculator to identify the exact rate for your ZIP code.

Practices using claims management software purpose-built for medical practices can automate prior authorization tracking, flag claims missing required documentation, and monitor denial patterns across structural heart codes including 93580. Practice management software features that integrate scheduling, documentation, and billing reduce the gap between procedure completion and clean claim submission.

Conclusion

Accurate billing for 93580 requires more than knowing the descriptor. The congenital vs. acquired defect distinction, NCCI edit exposure with catheterization codes, payer-specific prior authorization requirements, and device billing via HCPCS C1817 all create points of failure that drive denials and post-payment audits.

Cardiology billing teams that combine thorough operative documentation with systematic pre-bill review recover more on first submission. Pabau’s claims management tools support that workflow by centralizing authorization tracking and documentation attachment in one platform. To see how Pabau handles complex procedure billing end to end, book a demo.

Continue your research

Need a complete overview of CPT coding principles? What practice management software does explains how integrated billing platforms streamline CPT code tracking and claim submission workflows.

Coding other specialty procedures? IVF CPT codes covers the procedure codes, documentation requirements, and payer considerations for reproductive medicine billing.

Looking to reduce documentation burden across your cardiology practice? Digital intake and consent forms in Pabau capture structured pre-procedure information directly into the patient record, supporting clean claim submission.

Frequently Asked Questions