The patient is a 69-year-old woman with defibrillation-related cardiac arrest. She has an extensive history of heart disease as well as prior cardiovascular surgery, and pacemaker placement in 1997. A cath, which was performed earlier, revealed normal coronaries. The cardiologist then tested the existing pacemaker and found it was not performing adequately. The skin was also starting to show erosion. Based on these findings, the cardiologist decides to place an implantable cardioverter defibrillator (ICD).
Editors Note: We have condensed the following report from the cardiac catherization lab to describe the procedure relating to coding and reimbursement.
Because the patient had very little subcutaneous tissue or muscle tissue in the pectoral regions, the cardiologist elected to place the system in the abdomen.
Using Xylocaine 1% local anesthesia, a left delta pectoral incision was made and cephalic vein cutdown made. The Medtronic ICD lead Model 6945 (100 cm) was introduced. The lead was then secured to the underlying subcutaneous tissue and a loop made in the delta pectoral region. Another sleeve was anchored. The lead was then tunneled down to the abdomen where an incision was made and using blunt dissection, a pocket was fashioned and irrigated with antibiotic solution. A Medtronic Gem 7227CX ICD was connected and then placed in the abdominal pocket and anchored to the underlying subcutaneous tissues. The subcutaneous tissue and subcuticular tissue was closed. Prior to closure of the skin sutures, V-fib induction was performed. The first episode of ventricular fibrillation failed at 8 joules, but at 14 joules was successful in converting the rhythm to sinus.
A second episode of ventricular fibrillation was created and terminated promptly to sinus rhythm with a 14 joules shock.
Attention was geared to removal of the existing pacemaker system. The lead, with its significantly reduced impedance, was a problem. In addition, the atrial lead was nonfunctional, given the patients chronic atrial fibrillation. An incision was made over the area of the existing generator and this was carefully explanted. The leads were then placed in a cap and secured and placed back in the pocket. The existing pocket was irrigated using antibiotic solution and the subcutaneous tissue and subcuticular tissue.
There were no complications and the patient left the cardiovascular lab in satisfactory condition.
Lets look again at the report from the cardiac cath lab to determine the proper procedural codes.
First, the note describes the insertion of a complete cardioverter-defibrillator system with leads. The new lead was introduced and tested, then secured in place. A tunnel was formed to bring the lead from the cephalic vein area through the abdomen, where a new skin pocket was formed to place the new cardioverter-defibrillator.
Therefore, the CPT code for the placement of the new system is 33249 (insertion or replacement of implantable cardioverter-defibrillator leads; by other than thoractomy; with insertion of cardio-defib pulse generator).
Tip: If a new defibrillator unit had been inserted into the original skin pocket and attached to existing leads, use 33240 (insertion or replacement of implantable cardioverter-defibrillator pulse generator only). If the defibrillator or leads were repaired rather than replaced, use 33242 (repair of implantable cardioverter-defibrillator pulse generator and/or leads).
Next, the chart note describes how the new system was tested; use code 93641 (electrophysiologic evaluation of cardioverter-defibrillator leads at time of initial implantation or replacement; with testing of cardioverter-defibrillator pulse generator).
Finally, once the installation of the new system was complete, the old pacemaker was removed and the old leads were left in place in the original pocket. This service is represented by 33241 (removal of implantable cardioverter-defibrillator pulse generator only).
Tip: If the complete system, including the leads, is removed, use 33243 or 33244, depending on the approach.
How to Bill
1. CPT Codes.
Code the primary procedure as 33249, (insertion of ICD). Append the -51 modifier (multiple procedures) to 33241 (removal of ICD only) as well as a -26 modifier signifying the professional component.
Although fluoroscopy is usually performed during this procedure, our sources note two reasons why it shouldnt be billed. First of all, there is no indication within the note that fluoroscopy was used. Second, fluoroscopy is considered an inherent part of the catheterization because it is the mechanism used to view the cath as it is inserted into the blood vessel; therefore, it should not be billed separately.
2. Diagnostic Codes.
For the atrial fibrillation, use 427.31. But dont use heart failure as a diagnostic code for the explantation. The reason the removal needed to occur was that the old device failed, so use 996.04 (mechanical failure of automatic implantable cardiac defibrillator).
Therefore, coding for this procedure would appear as follows:
1. 427.31 (atrial fibrillation)
2. 996.04 (mechanical failure of ICD)
33241-51 2, 1
Editors Note: Advice for this case study was provided by the following sources: Susan Stradley, CPC, CCS-P, senior consultant for Elliott, Davis and Company, LLP, headquartered in Greenville, SC. Along with the 1999 CPT and ICD-9 manuals, references included Medicodes Coding Illustrated for Cardiovascular and Respiratory, Coders Desk Reference, as well as Aspen Publishers CPT Made Easy and American College of Cardiologys Practical Reporting of Cardiovascular Services and Procedures.