Cardiology Coding Alert

Remember: You should report Z95.0 for the presence of a pacemaker.

In the recent 2021 HEALTHCON session “Cardiac Anatomy, Pacers, Defibrillators, and Stents,” Aisha Hollingsworth- Thomas, CPC, CPMA, CEMA, AAPC approved instructor and Victoria Hollingsworth, RCIS, BS, discussed tips on how you can submit clean pacemaker and defibrillator claims in your cardiology practice. For example, you should know if the patient received a defibrillator or a pacemaker. You should also know how many leads are involved with the pacemaker.

Read on to learn more.

Tip 1: Understand Difference in ICDs Versus Pacemakers

The insertion of a cardiac implantable cardioverter-defibrillator (ICD) is a surgical procedure, according to Hollingsworth- Thomas. An ICD is implanted in patients who are at risk of sudden cardiac events due to sustained fibrillation or ventricular tachycardia, which may lead to death.

On the other hand, patients who require assistance with maintaining regular heart rhythm receive the implantation of a pacemaker, Hollingsworth-Thomas said. Pacemakers may be permanent or temporary.

Bottom line: A defibrillator shocks the heart when it stops beating, and it works to keep the heart on pace, Hollingsworth- Thomas explained. On the other hand, a pacemaker just works to keep the heart on pace.

Coding tip: A patient will receive either a defibrillator or a pacemaker, not both. However, sometimes you may see erroneous documentation of both devices. If you want to know which device you should report, it makes sense to go with the defibrillator because it does the act of both devices, Hollingsworth-Thomas said. The defibrillator shocks the heart when it needs to, and it keeps the heart on pace.

“I have never forgotten this coding tip because originally I was told that if I see both devices, just code the defibrillator, but it never really stuck,” Hollingsworth-Thomas added. “Just from the educational perspective, I think it’s nice to go into the why of the defibrillator.”

Tip 2: Choose Appropriate Code for Procedure Cardiologist Performed

When you report assistive cardiac devices, you must first check the medical documentation to know if it’s a pacemaker or defibrillator, said Hollingsworth-Thomas. Then you need to ask yourself what the cardiologist is doing to that device. Is he inserting, removing, revising, relocating, or programming it?

CPT^® offers numerous code choices for pacemakers and defibrillators, depending upon the service your cardiologist performed. You must also know how many leads are involved and if just leads are involved or if a pulse generator is involved, as well.

Some of the codes you will encounter include but are not limited to the following. (Note: This is not an exhaustive list).

Insertion: Here are some examples of insertion codes for pacemakers and implantable defibrillators:

• For an insertion of an initial pulse generator only with existing dual leads for a pacemaker, you should report 33213 (Insertion of pacemaker pulse generator only; with existing dual leads).
• For an insertion of transvenous single lead only without a pulse generator for a pacemaker or implantable defibrillator, you should report 33216 (Insertion of a single transvenous electrode, permanent pacemaker or implantable defibrillator).
• For an insertion of dual leads without a pulse generator for a pacemaker or implantable defibrillator, you should report 33217 (Insertion of 2 transvenous electrodes, permanent pacemaker or implantable defibrillator).

Removal: Here are some examples of removal codes for pacemakers and implantable defibrillators. (Note: This is not an exhaustive list.)

• For the removal of a pulse generator only without a replacement for a pacemaker, you should report 33233 (Removal of permanent pacemaker pulse generator only).
• For the removal of a pulse generator with replacement pulse generator only for a multiple lead system (transvenous) for an implantable defibrillator, you should report 33264 (Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; multiple lead system)
• For removal of a transvenous electrode only in a dual lead system for a pacemaker, you should report 33235 (Removal of transvenous pacemaker electrode(s); dual lead system).

Insertion or replacement: You will also see some codes that cover either the insertion of a new or replacement of a permanent pacemaker. These include the following:

• 33206 (Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial)
• 33207 (Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular)
• 33208 (Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular)

Tip 3: Don’t Forget About Z-Codes

From a diagnostic perspective, CPT^® does offer presence of a pacemaker and defibrillator Z-codes.

You can report these codes to indicate the devices when the patient comes in for a service not related to the implantation or repositioning of those devices because it may affect their condition or disease management if the patient has the device, Hollingsworth-Thomas said. You definitely want to document this information on the patient’s medical record.

These codes are as follows:

• Z95.0 (Presence of cardiac pacemaker)
• Z95.810 (Presence of automatic (implantable) cardiac defibrillator)

Bottom line: These codes are not to be used or confused with the actual device implantation or when the cardiologist is managing the device, Hollingsworth-Thomas emphasized.

Tip 4: Putting it Together With an Example

Hollingsworth offered the following clinical example to help you brush up on your assistive cardiac device coding skills.

Example: The patient presents with pain in a pocket. Local anesthesia was obtained subcutaneously. The cardiologist made an approximately 5cm incision at the surgical site. The cardiologist carried the incision down through the subcutaneous tissue to premuscular fascia by using dissection and electrocautery. The cardiologist then incised the ICD pocket capsule and extracted the old generator from the pocket. The cardiologist carefully dissected the leads away, creating a new submuscular pocket. He washed the pocket with antibiotic solution. Next, he applied thrombin powder to assist with hemostasis. Then, the cardiologist tacked the ICD down to the posterior portion of the new pocket. After checking the pocket for hemostasis, he closed the pocket in three layers. The cardiologist never removed the leads from the ICD header.

Solution: You should report 33223 (Relocation of skin pocket for implantable defibrillator) for this scenario.

Editor’s note: Want more great info like this? You can now register for the upcoming 2021 HCON regional conferences: www.aapc.com/medical-coding-education/conferences/. Visit www.aapc.com for more info.