Here’s What You Need to Know About Mechanical Heart Pump Coding
Hint: Location and approach determine procedure code selection. Accurate mechanical heart pump coding begins with understanding what was treated, which device was used, and how the procedure was performed. For example, one type of pump, Impella®, provides temporary mechanical circulatory support for selected patients with severe cardiac dysfunction or during high-risk percutaneous coronary intervention (PCI). However, the presence of a pump does not establish a diagnosis or determine every reportable service. Coders must connect provider documentation with the applicable code definitions, reporting rules, and payer requirements. Understand the Device and Approach Left-sided Impella® devices move blood from the left ventricle into the aorta. Right-sided devices support circulation toward the pulmonary artery. This distinction matters because CPT® separates left-heart arterial insertion from right-heart venous insertion. The operative report should identify the model of the heart pump, supported ventricle, access vessel, insertion technique, and imaging used. Device names alone are insufficient. For example, an Impella® 5.5 placed through an axillary graft requires review of the documented access work and applicable coding guidance. An axillary cutdown does not automatically mean the pump should be coded as a surgically implanted durable ventricular assist device. Likewise, access-site documentation should distinguish vessel exposure, conduit creation, and any separately reportable repair. Select CPT® Codes According to Documentation Details For percutaneous left-heart pump placement using arterial access only, 33990 (Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; left heart, arterial access only) is the relevant insertion code. Right-heart placement through venous access uses 33995 (Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; right heart, venous access only). Both include radiological supervision and interpretation; avoid separately reporting imaging already included in the service. Removal requires attention to timing and laterality. Code 33992 (Removal of percutaneous left heart ventricular assist device, arterial or arterial and venous cannula(s), at separate and distinct session from insertion) describes removal of a percutaneous left-heart device, while 33997 (Removal of percutaneous right heart ventricular assist device, venous cannula, at separate and distinct session from insertion) addresses a percutaneous right-heart device. These codes require removal during a separate, distinct session from insertion. Removing a pump during the insertion session does not independently support these removal codes. Code 33993 (Repositioning of percutaneous right or left heart ventricular assist device with imaging guidance at separate and distinct session from insertion) applies to imaging-guided repositioning of either a right-side or left-side heart percutaneous device during a separate session. It is not limited to left-sided pumps. Document the reason for repositioning, timing, and guidance used. Routine positioning during initial placement is part of insertion. When mechanical heart pump support accompanies PCI, evaluate the coronary intervention separately under current PCI coding rules. Do not assume that every catheterization, angiogram, access procedure, or imaging service is additionally billable. Review bundling edits and modifier requirements against the actual services documented. Report the Underlying Diagnosis Diagnosis coding should reflect the provider’s findings and the circumstances of the encounter. Examples include R57.0 (Cardiogenic shock), I50.23 (Acute on chronic systolic (congestive) heart failure), and I50.811 (Acute right heart failure). Myocardial infarction coding requires the documented infarction type and, when applicable, the involved artery. Do not infer cardiogenic shock from hypotension, low cardiac output, vasopressor use, or Impella® placement alone. Similarly, an ejection fraction does not independently establish the documented heart failure type or acuity. Query when necessary to resolve incomplete or conflicting diagnoses. Postprocedural cardiogenic shock requires documentation supporting its relationship to the procedure; timing alone is insufficient. When applicable, T81.11XA (Postprocedural cardiogenic shock, initial encounter) identifies postprocedural cardiogenic shock during active treatment. Follow all relevant tabular instructions and sequencing rules. Transplant status also requires precision. Evaluation for transplantation does not automatically establish Z76.82 (Awaiting organ transplant status). Report that status only when supported, along with the underlying disease when appropriate. Case Example 1: Acute Myocardial Infarction With Cardiogenic Shock A patient presents with an acute STEMI involving the left anterior descending coronary artery and documented cardiogenic shock. The cardiologist inserts an Impella® CP through the femoral artery before performing coronary stenting. The pump remains in place until removal during a separate session two days later. Relevant codes include: Select the coronary intervention code based on the complete PCI report and applicable coding rules. Determine diagnosis sequencing from the circumstances of admission. Coding takeaway: The separate removal session supports consideration of 33992. Removal during the insertion session would not support separate reporting of this code. A patient with dilated cardiomyopathy develops documented acute-on-chronic systolic heart failure and cardiogenic shock. The surgeon places an Impella® 5.5 through a right axillary artery conduit while the patient undergoes heart transplant evaluation. The record does not establish transplant waiting-list status. Relevant diagnosis codes include: Evaluate 33990 for pump insertion and review the operative report for any separately reportable axillary exposure or conduit creation. The device model and access vessel alone do not establish the complete procedure code assignment. Do not assign Z76.82 solely because transplant evaluation is underway. Coding takeaway: Distinguish transplant evaluation from documented waiting status and review the access procedure separately from pump placement. Cristin Robinson, CPC, CPMA, CCC, CRC, CEMC,
Case Example 2: Heart Failure With Impella® 5.5 Placement
AAPC Approved Instructor, Education Coding Consultant, Bristol, Tennessee
