Set a Pace for Better Implantable Defibrillator Coding
Revitalize your coding expertise with the latest in fibrillation advancements.
Defibrillators help to prevent sudden death secondary to life threatening arrhythmias. They may provide a low-level shock or cardioversion for ventricular tachycardia, or a high level shock for ventricular fibrillation.
Procedural Approaches and Techniques
The system consists of a generator placed in the subcutaneous tissues, and one or more leads. A right ventricular (RV) defibrillating lead is placed to provide electrical shocks. A right atrial (RA) lead may be inserted to allow for dual pacing. A left ventricular (LV) lead may be placed in the coronary sinus for cardiac resynchronization therapy (CRT or biventricular pacing) in patients with heart failure. Leads usually are placed via a transvenous technique, but they may be implanted into the epicardium (on the outside of heart) during an open or endoscopic approach.
Recently, subcutaneous defibrillators have been introduced with a lead placed in the subcutaneous tissues. This obviates the need for transvenous or epicardial leads. The advantage is ease of placement, and fewer potential complications related to venous stenosis secondary to the lead, and/or infected leads within the heart. The subcutaneous system does not allow pacing as in a traditional transvenous system.
After insertion of a defibrillator, defibrillation threshold testing often is performed. The patient is sedated and placed into fibrillation to check the function of the implanted device.
The battery in the generator must be replaced over time. The CPT® codes to describe such replacement procedures (see the sidebar “Implanted Cardiac Device Codes” for code descriptions) include insertion of the new generator and removal of the existing generator. The leads are checked during the generator change. Leads may become displaced (which requires repositioning) or may be damaged or faulty (which requires repair or replacement with a new lead). When an existing lead is not useable, it may be left in place and capped, or removed. Removal can be difficult and may require the use of laser energy. Fluoroscopy is used in these cases, but is included in CPT® codes 33206-33249, 33262-33264, and 33270-33273.
Here’s a general run-down of associated procedures and applicable codes. A complete code list with descriptions is at the end of this article.
- 33249 describes insertion of a defibrillator, including the transvenous RV defibrillating lead +/- atrial lead.
- 33202 and 33203 describe open or endoscopic (respectively) insertion of epicardial leads.
- 33215 reports repositioning of an RA or RV lead. Insertion of a single transvenous new lead is reported with 33216; and for two new leads, report 33217.
- 33218 describes repair of a single existing lead; for repair of two leads, report 33220.
- 33223 describes relocation of a skin pocket. It is not used for revision of an existing pocket to accommodate a new generator.
- 33224 reports adding a LV lead for biventricular pacing to an existing system. Turn to 33225 when the physician adds an LV lead at the time of a new generator placement. Report repositioning of an LV lead with 33226.
- 33240 (single lead system), 33230 (dual lead), or 33231 (biventricular system with RV and LV leads +/-RA lead) describes insertion of a generator and connection to lead(s) already in place.
- 33241 describes removal of an existing generator (i.e., for infection). Report removal and replacement of a generator (e.g., battery is nearly depleted) for elective replacement indicator (ERI) with either 33262 (single lead generator), 33263 (dual lead), or 33264 (biventricular defibrillator with RV, LV and +/-RA leads).
- 33243 reports removal of defibrillator lead(s) by open thoracotomy; report 33244 for transvenous extraction.
- 93641 reports defibrillation threshold (DFT) testing at the time of placement or replacement of a generator. If DFT is performed at a later date (i.e., secondary to atrial thrombus), report 93642.
- 33249 reports a new RA and/or RV lead are placed at the time of a new generator placement for ERI. Do not report a replacement generator code plus new lead insertion code. In this scenario, also report 33241 for removal of the existing depleted generator.
- 33270 reports placement of a subcutaneous defibrillator system, which includes the generator, subcutaneous lead, and DFT testing, if performed.
- 33271 describes insertion of a subcutaneous lead at a later date; report 33272 for removal and 33273 for repositioning. Report DFT testing performed at a different date of service for a subcutaneous defibrillator with 93644.
A Perfect Example
A 64-year-old male has a documented cardiac arrest due to ventricular fibrillation. Antibiotics are given and venography is performed to help guide venous access. A subclavicular pocket is created. The subclavian vein is accessed and three wires are placed. A defibrillating lead is placed into the RV. Next, a pacing lead is placed into the RA. Finally, the coronary sinus is cannulated and an LV lead is placed into the coronary sinus. The generator is brought to the field where the three leads are connected to the generator. The patient is sedated and DFT testing is performed and found to be adequate. The incision is closed in layers.
CPT® codes for this case include 33249-Q0 (insertion of RV and RA leads and generator), 33225 (LV lead), and 93641 (DFT testing). Do not code for routine venography during defibrillator placement. Fluoroscopy is included in the insertion.
The defibrillator was placed for ventricular fibrillation: ICD-10-CM I49.01 Ventricular fibrillation.
The implantation was for secondary prevention of sudden death, which is covered per the Medicare National Coverage Determination. The patient’s data does not have to be submitted to the registry for coverage, and modifier Q0 is not necessary. If the data is submitted to the registry, modifier Q0 can be appended but is optional (see companion article “Establish Medical Necessity for Implantable Cardioverter-defibrillators” ).
33202 Insertion of epicardial electrode(s); open incision (eg, thoracotomy, median sternotomy, subxiphoid approach)
33203 endoscopic approach (eg, thoracoscopy, pericardioscopy)
33215 Repositioning of previously implanted transvenous pacemaker or implantable defibrillator (right atrial or right ventricular) electrode
33216 Insertion of a single transvenous electrode, permanent pacemaker or implantable defibrillator
33217 Insertion of 2 transvenous electrodes, permanent pacemaker or implantable defibrillator.
33218 Repair of single transvenous electrode, permanent pacemaker or implantable defibrillator
33220 Repair of 2 transvenous electrodes for permanent pacemaker or implantable defibrillator.
33223 Relocation of skin pocket for implantable defibrillator
33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator)
+33225 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (List separately in addition to code for primary procedure)
33226 Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, insertion and/or replacement of existing generator).
33230 Insertion of implantable defibrillator pulse generator only; with existing dual leads
33231 with existing multiple leads
33240 with existing single lead
33241 Removal of implantable defibrillator pulse generator only
33243 Removal of single or dual chamber implantable defibrillator electrode(s); by thoracotomy
33244 by transvenous extraction
33249 Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual chamber
33262 Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; single lead system
33263 Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; dual lead system
33264 Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; multiple lead system
33270 Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed
33271 Insertion of subcutaneous implantable defibrillator electrode
33272 Removal of subcutaneous implantable defibrillator electrode
33273 Repositioning of previously implanted subcutaneous implantable defibrillator electrode
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
93642 Electrophysiologic evaluation of single or dual chamber transvenous pacing cardioverter-defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters)
93644 Electrophysiologic evaluation of subcutaneous implantable defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters)
Occasionally, there are recalls for defibrillator leads and generators. The hospital may receive a replacement device at no cost or at a reduced cost. When a credit for the replaced device is 50 percent or greater than the cost of the device, hospitals must report the amount of the credit in the amount field for value code “FD” (credit received from the manufacturer for a replaced medical device) on the UB-04 claim form.
David Dunn, MD, FACS, CIRCC, COC, CCVTC, CCC, CCS, RCC, vice president of ZHealth Publishing, oversees physician coding. He coauthors the Vascular & Endovascular Surgery Coding Reference and the new Cardiothoracic Surgery Coding Reference from Dr. Z’s Medical Coding Series, and is a contributor to the Interventional Radiology Coding Reference and the Diagnostic & Interventional Cardiovascular Coding Reference. Dunn served as president of the AAPC National Advisory Board from 2013-2015, and is a member of the Nashville, Tenn., local chapter.
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- Set a Pace for Better Implantable Defibrillator Coding - August 1, 2016