Learn VAD Management to Help Failing Coding
Understanding documentation is the key to accurate coding.
By Julie-Leah J. Harding, CPC, RMC, PCA, CCP, SCP-ED, CDI
A ventricular assist device (VAD) partially or completely takes over the function of a failing heart. VADs are intended for short-time use for patients who have had cardiac surgery or a recent heart attack or who need a bridge to transplant. Long-term use may be required for patients with chronic congestive heart failure. VADs assist either the right ventricle (RVAD) or the left ventricle (LVAD), or both at once (BiVAD), depending on the patient’s underlying heart disease. These devices have come a long way in a relatively short time. Medical coding has had to keep pace with technology.
For professional billing of VAD insertion or pump replacement, select from the following CPT® codes:
33975 Insertion of ventricular assist device; extracorporeal, single ventricle
33976 Insertion of ventricular assist device; extracorporeal, biventricular
33977 Removal of ventricular assist device; extracorporeal, single ventricle
33978 Removal of ventricular assist device; extracorporeal, biventricular
33979 Insertion of ventricular assist device, implantable intracorporeal, single ventricle
33980 Removal of ventricular assist device, implantable intracorporeal, single ventricle
33981 Replacement of extracorporeal ventricular assist device, single or biventricular, pump(s), single or each pump
33982 Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without cardiopulmonary bypass [no global period]
33983 Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, with cardiopulmonary bypass [no global period]
Example No. 1
The patient has orthotopic heart transplant with insertion of 10 mm GORE-TEX® graft from the left superior vena cava to the recipient’s right atrium, with removal of the BiVAD.
Report: 33978 for removal of the extracorporeal (outside the body), BiVAD.
Example No. 2
A thrombus in a Berlin heart LVAD occurs in a 21-year-old patient with dilated cardiomyopathy. The patient is transported to the operating room and placed on bypass. The pump head is changed to a 30 cc pump head, without complication.
Report: 33982 for replacement of intracorporeal VAD pump with bypass.
Example No. 3
A patient with dilated cardiomyopathy and end-stage left ventricular failure requires an emergent LVAD implantation.
Report: 33975 for insertion of an extracorporeal VAD, single ventricle.
Interrogation and Programming
Patients with a previously implanted VAD require periodic interrogation of the device. In 2010, CPT® introduced a new code to report this management: 93750 Interrogation of ventricular assist device (VAD), in person, with physician or other qualified health care professional analysis of device parameters (eg, drivelines, alarms, power surges), review of device function (eg, flow and volume status, septum status, recovery), with programming, if performed, and report. This code includes the physician analysis, review, and report. It also includes device programming, if performed. It has been assigned no global days.
Code 93750 is NOT reported with any of the surgical implantation codes (33975, 33976, 33979, 33981-33983), but typically is reported with an evaluation and management (E/M) visit. VAD management is considered a diagnostic service, which must be performed in person and includes a face-to-face assessment of all device functions. Components that must be evaluated include:
- Device parameters (e.g., alarms, drivelines, clots, infection, overall assessment of augmenting cardiac output, and power surges)
- Device function (flow/volume status, septum status, and recovery)
All of the above must be stated in detail, either in its own procedure note (if management is part of the daily rounding) or in its own paragraph (separate from the rounding note, if performed during rounding). Adjustments may not be needed each day, but each entry must support assessing the potential need.
Example No. 4
8 y/o with DCM titin mutation with end-stage HF, FTT, NSVT, s/p HW LVAD. Pt noted that the side of the bag felt damp, but no h/o spilling on the controller or driveline. Driveline examined and clean, no tears, no fluid within line. With readjustment of driveline at lug into controller, alarm stopped, but asked to come back to hospital to clean out receptacle of driveline connector.
HW programmer arrived this afternoon to perform cleaning, which required disconnecting and stopping VAD x3 for total of 1 minute. IV access was acquired, in case entropic support would be necessary.
Baseline VSS: HR 90, MAY 58
AM meds were held.
Driveline cleaned and was found to have small debris in connector (unknown substance, sent for histopathology to determine what it is). Pt tolerated being disconnected well. Pt felt lightheaded and complained of mild headache and nausea. HR increased quickly to 140, Pt felt pressure in the chest and lungs that resolved instantaneously with starting the pump again at RPM 2440. Flows resumed to 3.5-4.2 L/min and power 3.2 watts.
Post procedure: Pt felt improved with no further headache. Observed for 2 hours post with no events. VAD settings: 2440 RPM; calculated CO: 3.2-4.5 L/min; power: 3.2 watts; alarm settings: low flow 2 L/min and high power 4 watts.
Report: A patient on VAD often has numerous issues being managed. One such scenario is where a patient remains on VAD but has failure to thrive along with acute or chronic congestive heart failure and is awaiting transplant. For the services associated with this case, you may bill the appropriate E/M code with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service and report 93750 with cardiomyopathy (425.4 Other primary cardiomyopathies) and VAD status (V43.21 Organ or tissue replaced by other means, heart assist device).
If the VAD management documentation is too limited, report an E/M service only. For example, you may have a patient who remains in the cardiac intensive care unit, intensive care unit, or possibly a step down to the telemetry unit, who continues to use the VAD device. If the patient has been an inpatient for some time, the note may simply state, “The VAD setting remains appropriate and unchanged.” With such a limited capture, do not report 93750; instead, claim only the subsequent critical care or inpatient level of service.