Part 2: Catch up on reporting of ablations and newer technology procedures.
by David Dunn, MD, FACS, CIRCC, CPC-H, CCC, CCVTC
As we learned in Part 1 of this two-part series (see “Changes Plus More Changes for Cardiology in 2013,” page 40-43, January’s Cutting Edge), the new year brings significant changes to cardiology coding. This month, we cover CPT® coding in 2013 for transcatheter aortic valve replacement (TAVR), ventricular assist devices, electrophysiology ablations, subcutaneous defibrillators, intracardiac ischemia monitoring systems, and left atrial (LA) hemodynamic monitoring systems.
Transcatheter Aortic Valve Replacement/Implantation (TAVR/TAVI)
Codes 0256T-0259T are deleted for 2013, replaced by new codes for TAVR/TAVI. To make it easier to differentiate the services, here’s a list of the new codes with abbreviated descriptors:
33361 TAVR, percutaneous femoral approach
33362 TAVR, open femoral approach
33363 TAVR, open axillary approach
33364 TAVR, open iliac approach
33365 TAVR, transaortic approach (eg, median sternotomy)
0318T TAVR, open transapical approach (eg, left thoracotomy)
+33367 Cardiopulmonary bypass support for TAVR, percutaneous peripheral arterial and venous cannulations
+33368 Cardiopulmonary bypass support for TAVR, open peripheral cannulations
+33369 Cardiopulmonary bypass support for TAVR, central (eg, aorta, right atrium, pulmonary artery) cannulations
Here are some tips for applying these new codes correctly:
- The only currently approved device is the Sapien valve. It’s indicated for patients with severe aortic stenosis who are not surgical candidates (determined by a cardiothoracic surgeon).
- The three add-on codes for cardiopulmonary bypass (C-P bypass), when performed, are also based on approach. Only one C-P bypass code is submitted during TAVR.
- Open femoral (34812) and open brachial access (34834) are included in the TAVR codes.
- Temporary pacemaker placement for rapid pacing during TAVR, as well as catheter placements and balloon valvuloplasty, are included.
- Swan-Ganz placement and aortic/left ventricular (LV) measurements and imaging to guide and complete the TAVR are included.
- If a complete heart catheterization is performed, you may report it if no prior diagnostic study was performed or a suboptimal study is documented, or if there has been a clinical change in the patient since the prior study or during the procedure.
- Code for other percutaneous coronary/cardiac interventions that are performed and medically indicated.
- You may code for ventricular assist device or intra-aortic balloon pump (33990, 33991, 33967, 33970), if performed.
- TAVR requires two physicians to complete the procedure. Codes 33361-33365 and 0318T Implantation of catheter-delivered prosthetic aortic heart valve, open thoracic approach, (eg, transapical, other than transaortic) require modifier 62 Two surgeons for physician billing. For example, each physician would report 33361-62 for a percutaneous TAVR. The C-P bypass codes do not have this requirement.
Example: An elderly patient with severe aortic stenosis, who is not a surgical candidate, presents for a TAVR procedure. This is performed with C-P bypass via femoral cut-downs and rapid pacing with a temporary pacer. The TAVR is performed via percutaneous approach.
Correct codes would be:
33361 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach
+33368 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with open peripheral arterial and venous cannulation (eg, femoral, iliac, axillary vessels) (List separately in addition to code for primary procedure)
Note: Do not report the temporary pacemaker.
Ventricular Assist Device (VAD)
Codes 0048T and 0050T for VAD are deleted and replaced by new, Category I CPT® codes. For easy reference, here are abbreviated descriptors:
33990 Insert VAD, percutaneous, arterial access only, ie, Impella® device
33991 Insert VAD, percutaneous, both arterial and venous access with transseptal puncture, ie, TandemHeart™ device
33992 Removal of VAD
33993 Repositioning of VAD
Follow these tips for proper coding:
- VADs are for use in patients with impaired LV function. The new aforementioned codes are for percutaneous VADs.
- Impella® device is via arterial access only, with a single catheter that forcefully removes blood from the LV via the distal portion of the catheter and discharges it into the proximal aorta.
- TandemHeart™ device has both venous and arterial access. The venous catheter is placed into the LA via a transseptal puncture and removes oxygenated blood from the left LA back to the TandemHeart™ device (external on patient), and then returns it into a second catheter, placed usually via the femoral artery.
- You may report 34812 Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral when an open arterial exposure is performed to accommodate the larger catheters used in percutaneous VADs.
- Routine closure of artery is not reported separately.
- Removal and repositioning codes can only be used when at a different encounter. If on the same date of service but a different encounter, append modifier 59 Distinct procedural service to either 33992 Removal of percutaneous ventricular assist device at separate and distinct session from insertion or 33993 Repositioning of percutaneous ventricular assist device with imaging guidance at separate and distinct session from insertion.
- If VAD is placed prophylactically for an intervention and removed at its conclusion, do not report 33992.
- Repositioning of a percutaneous VAD without imaging guidance is not a reportable procedure.
- If an existing VAD is removed and replaced with a new VAD, code this as a new device placement. Do not report 33992 because the removal is bundled into the new device placement code.
Electrophysiology ablation codes 93651 and 93652 are deleted. New abbreviated versions of the codes are:
93653 Comprehensive electrophysiologic (EP) evaluation with ablation of supraventricular tachycardia (SVT)
93654 Comprehensive EP evaluation with ablation of ventricular tachycardia
+93655 Additional ablation of discrete mechanism of arrhythmia distinct from the primary ablation treated
93656 Comprehensive EP evaluation with ablation of atrial fibrillation via pulmonary vein isolation
+93657 Additional ablation of left or right atrium for a-fib remaining after pulmonary isolation at same setting
Use these helpful tips for proper EP ablation coding:
- The five new ablation codes all include a diagnostic EP study at the time of ablation.
- Do not submit any combination of 93653, 93654, and 93656 together. If an additional mechanism is ablated, use add-on code +93655 or +93657.
- With ablation of SVT (93653), you may report mapping (+93609 Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary procedure) or +93613 Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure)), transseptal procedure (+93462 Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (List separately in addition to code for primary procedure)), and LV pacing/recording (+93622 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left ventricular pacing and recording (List separately in addition to code for primary procedure)), when performed.
- Ablation of VT (93654) includes 3-D mapping (93613) and LV pacing/recording (93622), when performed. You can report transseptal procedure (93462), when performed.
- Pulmonary vein isolation for a-fib (93656) includes the transseptal procedure (93462) and LA pacing/recording (+93621 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separately in addition to code for primary procedure)), when performed. You can report mapping (93609 or 93613) and LV pacing/recording, when performed.
- There is a “gray zone” regarding 93623; CPT® states this code may be reported with 93656, but National Correct Coding Initiative (NCCI) Version 19.0 states not to report 93623 with any of the new ablation codes.
- Add-on code +93655 may be reported with 93653, 93654, or 93656, when performed.
- Add-on code +93657 may be reported only with 93656, when performed.
- Some of the parentheticals may need updating. For example, a parenthetical note instructs you to use +93622 only with 93620, but the CPT® introductory section states +93622 may be added to 93653. Likewise, only 93620 may be used with 93621, per a parenthetical note following 93621.
Example: A patient presents with atrial fibrillation. A complete EP study is performed, followed by a transseptal puncture under intracardiac echocardiography (ICE) into the LA. A 3-D map is created, followed by ablations performed to achieve pulmonary vein isolation. After this was done, there was evidence of continued a-fib and a decision was made to perform additional right atrial ablations. The a-fib then ceased.
The correct coding in this case is:
93662 Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation (List separately in addition to code for primary procedure)
Note: Do not code for the EP study (93620) or transseptal procedure (93462); they are included in 93656.
This year, CPT® adds new Category III codes for S-ICD systems. Shortened descriptions are:
0319T Insertion of complete system
0320T Insertion of electrode only
0321T Insertion of generator only
0322T Removal of generator
0323T Removal and replacement of generator
0324T Removal of electrode
0325T Repositioning of electrode and/or generator
0326T EP evaluation (defibrillation threshold testing)
0327T Interrogation of device
0328T Programming of device with iterative adjustments
This is a newer type of defibrillator for treatment of arrhythmias that is totally implanted in the subcutaneous tissues, including the defibrillating lead.
To apply the above codes, follow these tips:
- The generator and one lead are placed subcutaneously. This allows for easier insertion over traditional transvenous insertion of electrode, and results in fewer potential complications, such as venous stenosis and infected leads within the heart because the lead is in the subcutaneous tissues.
- This system does not allow pacing, as in a conventional defibrillator.
- To report removal of an existing subcutaneous lead and generator plus replacement with a new system, report 0322T, 0324T, and 0319T.
- At generator end of life, report replacement with 0323T when the depleted generator is removed and a new generator is inserted.
- Use the repositioning code 0325T when performed repositioning of an electrode and/or generator occurs at a different encounter than at the original insertion.
- Defibrillation threshold testing (DFT testing) involves induction of arrhythmia and evaluation of sensing and pacing for arrhythmia termination, as well as reprogramming as necessary, and is reported with 0326T.
- Report 0327T and 0328T at a different encounter than at the original placement for interrogation or programming of S-ICD (this is not DFT testing).
Intracardiac Ischemia Monitoring Device (IMD)
Also new for 2013 are Category III codes (with our abbreviated descriptions) for IMD:
0302T Insertion of complete system, or removal and replacement of both device and electrode
0303T Insertion of electrode only, or removal and replacement of electrode
0304T Insertion of device only, or removal and replacement of device
0305T Programming of device with iterative adjustment
0306T Interrogation of device
0307T Removal of IMD system
IMD (AngelMed Guardian® system) consists of an electrode placed into the right ventricle and a device. It monitors electrocardiogram signals for acute ST elevation changes and warns the patient via vibratory and auditory alerts. This allows the patient to potentially seek earlier treatment of impending ischemic events.
Consider these tips when applying the above codes:
- The removal of an existing IMD system and replacement with a new system is reported by the single code, 0302T.
- Report codes 0305T and 0306T at a different encounter than at original placement for interrogation or programming of IMD.
Left Atrial Hemodynamic Monitor
Finally, you’ll find new Category III codes for left atrial hemodynamic monitor. Easier-to-follow abbreviated descriptions are:
0293T Insertion of LA hemodynamic monitor, complete with module and pressure sensor lead
0294T Insertion of pressure sensitive lead at time of insertion of pacing cardioverter-defibrillator
This system monitors LA pressures to identify changes in patients with heart failure to allow potential earlier treatment.
Tips to apply these codes correctly include:
- You may use the above codes alone, or when inserted into combination-type defibrillator devices.
- Transseptal code 93462 is bundled with these codes, as is ICE (93662).
- Use 0294T with 33230 Insertion of pacing cardioverter-defibrillator pulse generator only; with existing dual leads, 33231 Insertion of pacing cardioverter-defibrillator pulse generator only; with existing multiple lead, 33240 Insertion of pacing cardioverter-defibrillator pulse generator only; with existing single lead, 33262-33264 Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator …, and 33249 Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber.
David Dunn, MD, FACS, CIRCC, CPC-H, CCC, CCVTC, is vice president of ZHealth. He oversees physician coding and instructs ZHealth educational programs, and contributes to Dr. Z’s Medical Coding Series. A graduate of Texas A&M University, he completed his M.D. at the University of Texas, his surgical residency at Scott & White Hospital, and his vascular surgery fellowship at Baylor College of Medicine. A diplomat of the American Board of Surgery, Dr. Dunn is also certified in vascular surgery. He is a fellow of the American College of Surgeons and a member of the Southern Association for Vascular Surgery. He is president-elect of the AAPC National Advisory Board.
February 1st, 2013
By Catrena Smith, CPC, CCS, CCS-P, and Elizabeth Giustina, CCS-P
A common misconception is that hospital coding is synonymous with inpatient coding, but hospitals provide many services in addition to inpatient care. Hospital coders may find themselves coding for different settings, such as the facility’s outpatient clinics, emergency department (ED), urgent care center, ambulatory surgery center (ASC), laboratory, observation unit, diagnostic radiology, and other departments.
To give you an inkling of what’s required of a hospital coder, we’ll focus on several aspects of hospital outpatient coding and assignment of evaluation and management (E/M) codes in the hospital/facility setting. We’ll also introduce you to Medicare’s Outpatient Prospective Payment System (OPPS) and the charge description master.
Facility Bill Includes All But the Doc
Outpatient coding captures facility expenses. All things must be recouped in the facility’s reimbursement, including the cost of the operating room, the nursing staff, the medical supplies, all salaries, all utilities, and building maintenance. The physician’s service fee, however, is not usually part of this bill.
E/M Code Assignment
When most coders think of E/M coding, they think of the Centers for Medicare & Medicaid Services’ (CMS) 1995 and 1997 Documentation Guidelines for Evaluation and Management Services. These systems are point based and rely heavily on the documentation level in the three key components of history, examination, and medical decision-making. These are national guidelines used in physician E/M coding.
Hospitals do not follow the 1995 or 1997 documentation guidelines for reporting their facility services; national facility E/M coding guidelines do not exist. There is, however, a set of standards, and each facility is responsible for developing and using its own internal E/M code assignment guidelines. These guidelines are based on the intensity of the service(s) documented and provided. However, coders must be careful because the level of E/M assigned for professional services will not always match the facility E/M level.
The American College of Emergency Physicians (ACEP) offers an easy method for assigning E/M levels for EDs, basing levels on possible interventions and including potential symptoms/examples to support those interventions. An article and corresponding E/M guide can be found on ACEP’s website (www.acep.org).
In the E/M grid provided on the ACEP website, levels are building blocks: The higher E/M levels could include interventions from the lower levels. For example, let’s take a look at the options for patients treated for trauma. According to ACEP’s E/M grid:
- A patient seen for a simple trauma with no X-rays is reported with 99282 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity.
- A patient seen for a minor trauma (with potential complicating factors) is reported with 99283 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity.
- A patient treated for blunt/penetrating trauma with limited diagnostic testing is reported with 99284 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity.
- A patient with blunt/penetrating trauma requiring multiple diagnostic tests is reported with 99285 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity.
As the possible interventions and potential symptoms increase, so does the reportable E/M level.
Medicare’s Hospital OPPS
The OPPS was developed in 2000 to reimburse certain services in the outpatient setting. Often, the payment is made in the Ambulatory Payment Classification (APC). Although not all services are paid through the APC, the calculation of the reimbursement is based on a package of services. The services included in the APC are not individually paid.
For example, for 2012, CMS proposed APC 8009 Cardiac resynchronization therapy with defibrillator composite, which combined payment for CPT® codes 33225 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (including upgrade to dual chamber system and pocket revision) (List separately in addition to code for primary procedure) and 33249 Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber.
This does not mean, however, that all outpatient services provided on the same date of service are included in the APC.
Find more information about OPPS on the CMS website:
Charge Description Master
The APC is based on a HCPCS Level I (CPT®) or Level II code and medical necessity, often determined by the associated ICD-9-CM codes. Many hospitals have a financial system that will assign the HCPCS code using a charge description master (CDM). The CDM is often invisible to the person assigning the financial code and to the coder. The financial code may be a general ledger code, an inventory code, or other description. Using a dictionary or decision tree, the facility computer system will look at the general ledger code and the patient insurance information to assign the HCPCS code and revenue codes (used to summarize all services within a department on the bill).
Before final processing, the coding department should look at the charges, assign the diagnosis codes, and ensure the services are medically appropriate (i.e., confirm medical necessity). The billing department may also look at the bill prior to submission to verify insurance coverage. Using the encoders, insurance company edit tools, and National Correct Coding Initiative (NCCI) edits, both departments may verify that all charges are included to ensure prompt, accurate payment.
Health insurance management (HIM) and billing departments often have predefined computer parameters to review services. For example, the date requirement may be “any account five days post discharge,” and a minimum dollar amount, such as “any account over $100.” Each coder may have a predefined set of work parameters, or work lists, to review. For example:
- Coder Amy may look at all Medicaid pediatric accounts.
- Coder Betty may look at all Medicaid adult accounts.
- Coder Carol reviews all Medicare with a last name range of A-L.
This process allows coders to more easily conduct a review of charges compared to the medical record to detect any additional or missing charges, and also verify assignment of all diagnoses. For example, if there are magnetic resonance imaging (MRI) results, but no charge, the bill may be placed on hold.
The outpatient bill should reflect the actual services rendered, leading to proper reimbursement. The assignment of accurate and compliant codes allows facilities to be properly reimbursed for the quality care they provide.
Catrena Smith, CPC, CCS, CCS-P, is owner of Access Quality Coding and Consulting, LLC in Orange Park, Fla. Access Quality Coding and Consulting provides coding education and training, auditing, coding, and account management services in hospital and physician settings.
Elizabeth Giustina, CCS-P, has worked in many settings, including the Military Health System, inpatient and outpatient hospitals, and physicians’ offices. She works for First Class Solution as a consultant for ICD-10 documentation improvement, and also does CPT® auditing and coding.
December 1st, 2012
The Centers for Medicare & Medicaid Services (CMS) has posted April 2012 changes to billing instructions for payment policies implemented in the hospital Outpatient Prospective Payment System (OPPS). The April 2012 updated Integrated Outpatient Code Editor (I/OCE) and OPPS Pricer will reflect the HCPCS Level II, ambulatory payment classification (APC), HCPCS modifier, and revenue code additions, changes, and deletions as identified in change request (CR) 7748. The April 2012 revisions to I/OCE data files, instructions, and specifications are provided in CR 7751, “April 2012 Integrated Outpatient Code Editor (I/OCE) Specifications Version 13.1.”
1. For services provided on or after Jan. 1, 2012, the descriptor for CPT® 33249 has been changed to read “Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber.” Due to clinical inappropriateness, this has prompted the removal of HCPCS Level II code C1882 Cardioverter-defibrillator, other than single or dual chamber (implantable) from the list of device codes required to be billed with CPT® code 33249 on the procedure-to-device edit list. This change is retroactive to Jan. 1, 2012.
2. For new service (fluorescent vascular angiography), HCPCS Level II code C9733 Non-ophthalmic fluorescent vascular angiography (SI = Q2 and APC = 0397, vascular imaging) is assigned for $154.87 payment (minimum unadjusted copayment = $30.98) under the OPPS, effective April 1, 2012. HCPCS Level II code C9733, assigned to APC 0397, describes SPY® Fluorescence Vascular Angiography and other types of non-ophthalmic fluorescent vascular angiography.
3. Drugs and biologicals with OPPS pass-through status, effective April 1, 2012, are:
C9288 Injection, centruroides (scorpion) immune f(ab)2 (equine), 1 vial
C9289 Injection, asparaginase Erwinia chrysanthemi, 1,000 international units (I.U.)
C9290 Injection, bupivacaine liposome, 1 mg
C9291 Injection, aflibercept, 2 mg vial
4. Payment rates for certain HCPCS Level II codes effective July 1- Sept. 30, 2011 are:
||Corrected Payment Rate
||Corrected Min. Unadjusted Copayment
||Dimethyl sulfoxide 50% 50 ML
||Iron sucrose injection
||Inj melphalan hydrochl 50 MG
5. The following HCPCS Level II codes describe products that can be used as skin substitutes (They will be separately paid only when used with one of the CPT® codes describing the application of a skin substitute (15271-15278)):
|HCPCS Level II Code
||Integra Meshed Bil Wound Mat
||EpiFix wound cover
||Endoform Dermal Template
||Skin substitute, NOS
||Oasis wound matrix
||Oasis burn matrix
||Integra flowable wound matri
||Matristem wound matrix
||Oasis Ultra Tri-Layer Matrix
For the complete CR, see CMS Transmittal 2418.
March 16th, 2012
New usage and definitions have changed code selection significantly from 2011.
By David B. Dunn, MD, FACS, CIRCC, CPC-H, CCC
Once again in 2012, CPT® includes significant changes to codes for pacemakers and cardioverter-defibrillators, including nine new codes, 14 code revisions (several of which completely change code use in comparison to 2011), and new definitions for pacemakers and defibrillators. A single lead system now denotes pacing and sensing in one chamber; a dual lead system denotes pacing and sensing in two chambers; and a multiple lead system denotes pacing and sensing in three or more chambers.
The best way to evaluate the new and revised codes is to group them according to the procedures performed (new codes are indicated with a circle; revised codes are indicated with a triangle).
The codes for the insertion of a generator only when the existing leads are already in place are:
33212 33240 Existing single lead
33213 33230 Existing dual leads
33221 33231 Existing multiple leads
– Use of these codes is expected to be infrequent.
– No generator is removed with these codes.
The codes for the removal of an existing generator and its replacement with a new generator for battery depletion/end-of-life indicators are:
33227 33262 Single lead system
33228 33263 Dual lead system
33229 33264 Multiple lead system
– No leads are inserted or replaced with these codes.
– Removal codes 33233 and 33241 are not reported with these codes.
The codes for the insertion of the initial system or replacement of the existing generator and new lead(s) are:
33206 New generator and right atrial lead
33207 New generator and right ventricular lead
33208 New generator and right atrial and ventricular leads
33249 New generator and lead(s) in right atrium and/or ventricle
– Report 33233 (pacemaker) or 33241 (defibrillator) when an existing generator is removed. An exception occurs for an upgrade from single pacemaker to dual pacemaker; report 33214, which includes removal of existing generator, a new lead, and a new generator.
The codes for an extraction of transvenous leads are:
33234 Single lead pacemaker system, atrial or ventricular
33235 Dual lead pacemaker system
33244 Defibrillator, one or more leads
The codes for the repair of pacemaker/defibrillator electrodes are:
33218 Single electrode
33220 Dual electrodes
The codes for the insertion of right atrial or ventricular pacemaker/defibrillator lead(s) are:
33216 Single lead
33217 Two leads
The codes for the insertion of left ventricular lead (includes pocket revision) are:
s33224 Attach to existing pacemaker or defibrillator generator
+s33225 Attach at time of insertion of new pacemaker/defibrillator generator
The codes for repositioning of the lead(s) are:
33215 Reposition of right atrial or right ventricular lead
s33226 Reposition of left ventricular lead
– Codes 33215 and 33226 include removal and replacement of the existing generator.
– Code 33215 x 2 is reported when both right atrial and right ventricular leads are repositioned.
The codes for the revision/relocation of pocket are:
– Do not use these codes for revision of pocket during replacements to accommodate a new generator.
The codes for the insertion/replacement of temporary pacemaker lead(s) are:
33210 Single chamber lead
33211 Dual chamber leads
– To report during a generator change, the patient must be documented as pacemaker dependent.
Pacemaker/defibrillator device evaluation codes 93279-93299 are included with codes 33206-33249 and should not be reported together. Defibrillation threshold testing (93640 Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement or 93641 Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement; with testing of single or dual chamber pacing cardioverter-defibrillator pulse generator) may be reported when performed with defibrillator insertion/replacement procedures.
Also this year, 71090 is deleted: Fluoroscopy is now included in 33206-33249. If no lead work is performed other than inspection with fluoroscopy, report 76000 Fluoroscopy (separate procedure), up to 1 hour physician time, other than 71023 or 71034 (eg, cardiac fluoroscopy).
PROCEDURE: Dual pacemaker pulse generator exchange.
PREPROCEDURE DIAGNOSIS: Complete heart block, pacemaker battery depletion.
PROTOCOL: Via a transfemoral venous approach, a temporary pacer is placed fluoroscopically with the lead tip in the RV and activated. The left chest is prepped and draped in sterile fashion. An incision is made over the pulse generator and generator, and redundant leads are removed from the pocket. The leads are disconnected from the pulse generator tested. The lead thresholds are adequate but an insulation breach of the right ventricular lead is repaired with a kit. A new dual generator is placed and attached to the RV and RA leads. The temporary pacer is removed.
The correct coding is:
33210 Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure)
33228 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system
33218 Repair of single transvenous electrode, permanent pacemaker or pacing cardioverter-defibrillator
The temporary pacer is separately coded because the patient was pacer dependent (33210). Removal of the old generator and placement of the new generator are bundled together into a single code (33228); therefore, you should not separately report 33233 Removal of permanent pacemaker pulse generator. The repair of a single lead (33218) is reported, as well. Fluoroscopy is included in all codes 33206-33249 and should not be reported separately.
David Dunn, MD, is vice president of ZHealth. He oversees physician coding and participates as an instructor for ZHealth educational programs and is a contributor to Dr. Z’s Medical Coding Series. A graduate of Texas A&M University, he completed his M.D. at the University of Texas, his surgical residency at Scott & White Hospital, and his vascular surgery fellowship at Baylor College of Medicine. A diplomat of the American Board of Surgery, Dunn is also certified in Vascular Surgery. He is a fellow of the American College of Surgeons, a member of the Southern Association for Vascular Surgery, and president-elect of AAPC’s National Advisory Board (NAB).
February 1st, 2012