Rethink Pacemaker and Defibrillator Coding in 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).