Advanced Search

Cardiology Coding Alert

Carriers Set the Pace on Billing for Biventricular Device Implantation

Published on Tue Jan 01, 2002

With the Food and Drug Administration's (FDA) approval of the Medtronic InSync cardiac resynchronization system in August 2001, the way was cleared for biventricular pacemaker implantation to help patients who have moderate to severe heart failure and remain symptomatic despite stable, optimal medical therapy.
 
Although CPT codes covers single- and dual-chamber pacemaker implantations, there are no codes to report biventricular pacemaker implantation, which involves placing leads into three separate areas of the heart, not only in the right atrium and right ventricle but also in the coronary sinus to stimulate the left ventricle. As a result, cardiologists and electrophysiologists have been receiving conflicting advice on how to code this relatively new procedure. Medtronic and the North American Society of Pacing and Electrophysiology (NASPE) recommend using one or more existing codes in addition to an unlisted-procedure code, but consultants like Nikki Vendegna, CPC, a cardiology coding and reimbursement specialist in Overland Park, Kan., recommend using only an unlisted-procedure code.
 
Until CPT addresses the problem, coders should ask carriers whether biventricular pacemaker implantation is covered and which codes to use.

Billing 33999

Coding specialists agree on using 33999 (unlisted procedure, cardiac surgery) to report biventricular pacemaker implantation, but they differ on whether 33999 should be billed alone.
 
NASPE President Eric N. Prystowsky, MD, recently recommended in a letter to NASPE members that, in addition to CPT 33999, the procedure be reported as either 33207 (insertion or replacement of permanent pacemaker with transvenous electrode[s]; ventricular) or 33208 ( atrial and ventricular). 

If fluoroscopic guidance is used, NASPE suggests adding 71090 (insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation). NASPE and Medtronic also recommend that 75860 (venography, sinus or jugular, catheter, radiological supervision and interpretation) be billed, with Medtronic suggesting in a press release that these codes be considered "given the similarity to brady pacing."
 
Note: Although the NASPE letter also recommends 36005 (injection procedure for extremity venography [including introduction of needle or intracatheter]) for the injection procedure, this code should not be used for coronary venography in light of revisions to the code in CPT 2002, i.e., the word "extremity" has replaced the word "contrast" in the descriptor.

Unlisted-Procedure Codes

The CPT Manual does not include detailed instructions on using unlisted-procedure codes; however, CPT Executive Committee members have said in the past that unlisted-procedure codes include the entire procedure and are not meant to describe a component of a procedure.
 
"When you use an unlisted surgical procedure code, you can't piecemeal parts of the surgery and bill them separately," Vendegna says. "The unlisted code is used to identify the complete procedure, which does not have its own code. All the components and everything the surgeon has done for the procedure are included in the code." She says this applies not only to implantation of the two right- side leads (described by 33208) but also to venography, fluoroscopy and anything else that the physician routinely uses to perform the service.  
 
"Venography is always performed with biventricular pacing. It's part of the procedure. The only time venography should be billed separately is when it is not routinely performed but is medically necessary for a particular patient at a particular time," she says. As a result, coders should use only 33999 when reporting biventricular pacer implantation. Medical records should accompany unlisted-procedure codes reported to carriers that may require such documentation to value the procedure accurately, she says. If the payer wants the unlisted procedure reported according to NASPE and Medtronic guidelines, i.e., in conjunction with 33208 and the other codes, Vendegna recommends that these instructions be obtained in writing.

What Carriers Want

Payment and coverage decisions vary among carriers. They may:
 
Pay for 33999 as a component, according to NASPE and Medtronic guidelines.
 
Pay for 33999 as the total procedure.
 
Not cover biventricular pacer implants.
 
Limit coverage to very restrictive diagnoses.
 
Evaluate each claim on a case-by-case basis.

The Medtronic press release notes that "each private payer's policy is unique. As a result, physicians will need to contact the patient's insurer to determine its specific policy on coverage for this therapy. Since device implants typically involve a 'prior authorization,' this can be handled through the normal prior authorization process." Given the variance in coverage among Medicare carriers for example, Noridian Government Services (Part B carrier for Alaska, Arizona, Colorado, Hawaii, Iowa, Nevada, North Dakota, Oregon, South Dakota, Washington and Wyoming) considers 33999 a component code, but Medicare Part B (the carrier in Kansas, Nebraska and northwest Missouri) prefers that 33999 be reported alone prior authorization or precertification will clarify a Part B carrier's billing preferences.
 
Medtronic is careful to advise cardiologists that any billing suggestions the company provides "do not replace seeking coding advice from the payer and/or your own coding staff. The ultimate responsibility for correct coding lies with the provider of service. Please contact your local carrier/payer for their interpretation of the appropriate codes to use for specific procedures." Medtronic also advises physicians to determine carrier preference through "the normal prior authorization process that typically must be obtained for device implants."

Calculating Charges

There are no RVUs assigned when an unlisted-procedure code is reported, so the fee must be calculated for services performed. A carrier following the recommendations of Medtronic and NASPE would use 33999 to report placement of the third lead (in the left ventricle).
 
Medtronic product manager Barbara Veath assures that  "cardiologists and electrophysiologists who have already performed the procedure are recommending codes that come as close to matching unlisted codes as possible in terms of RVUs and setting a price including 93620 (comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia) with modifier -26 (professional component) for electrophysiologists and 92982 (percutaneous transluminal coronary balloon angioplasty; single vessel) for cardiologists." Veath likens the use of these "reference" codes to the process used to establish RVUs for procedures. "We don't tell the physicians which code should be used as a reference. We want them to think about what is involved in the procedure and come up with an equivalent procedure to base their fee on," she says.
 
Note: Noridian accepts 33999 as a component code and values the procedure at 1.5 times the rate of 33216 (insertion or repositioning of a transvenous electrode [15 days or more after initial insertion]; single chamber [one electrode] permanent pacemaker or single chamber pacing cardioverter-defibrillator).
 
Vendegna suggests that a cardiologist who reports an unlisted-procedure code only consider the complexity of the entire service and the expertise required to perform it, as well as the length of the entire service, to arrive at a fair price for this extensive procedure. No other procedure that cardiologists perform can serve as a model for the complete biventricular implant, Vendegna says, and the cardiologist should dictate a detailed operative report to accompany the claim.

Other Articles in this issue of

Cardiology Coding Alert

View All