Cardiology Coding Alert

CPT now contains a handful of brand-new pacemaker and cardioverter defibrillator codes, including freshly minted codes for biventricular procedures, and if you're not up-to-speed on the latest, you could soon be losing out on precious reimbursement dollars.

Even so, as this issue goes to press, CMS has delayed release of its final Physician Fee Schedule for 2003. Coding consultants say this delay in releasing relative value units (RVUs) for these codes could mean that if you bill them before the schedule goes into effect, you will likely receive denials. But the RVUs will go into effect this year, so billers and coders should be ready.

To code biventricular procedures accurately, you must have a clear understanding of whether the cardiologist is inserting a new pacemaker system with biventricular capability or upgrading an old system. You should also know how to apply the new code for coronary sinus lead repositioning.

Swap 33999 for New Codes

CPT 2003 contains three new codes that specifically address biventricular device implantation and coronary sinus lead repositioning:

Previously, cardiology coders used 33999 (Unlisted procedure, cardiac surgery) to report biventricular device implantation, in addition to 33207 (Insertion or replacement of permanent pacemaker with transvenous electrode[s]; ventricular) for right and left ventricular pacing or 33208 ( atrial and ventricular) for right atrium and biventricular pacing. CPT's inclusion of the new codes in 2003 eliminates the need for an unlisted-procedure code to describe the additional left-ventricular lead insertion, coding consultants confirm.

The New CPT Code approval process started before Medtronic Inc. received U.S. Food and Drug Administration (FDA) authorization for its InSync biventricular pacing system in August 2001, says Amy Melnick, director of government relations for the North American Society of Pacing and Electrophysiology (NASPE).

"Our members were part of the clinical trials, and we knew, based on the trial results, that the device would be approved," Melnick says. She notes that NASPE is considering developing new codes for remote monitoring of pacemakers.

Biventricular Devices Benefit CHF Patients

Typically, patients with advanced degrees of congestive heart failure (CHF) receive biventricular implants. Consequently, coders should be familiar with the diagnosis codes for CHF (428.0-428.9), including the new heart failure codes for systolic (428.20-428.23), diastolic (428.30-428.33), and combined systolic and diastolic (428.40-428.43) heart failure. These new codes also require physicians to specify whether the CHF is acute, chronic, acute on chronic, or unspecified.

Patients with progressive CHF have weakened heart muscles in the left ventricle, the main pumping chamber of the heart. This frequently results in loss of synchrony with other heart chambers and decreased pumping capability.

Traditional dual-chamber pacemakers pace only the right atrium and right ventricle, but biventricular pacing systems include pacing leads in these positions, as well as a third lead that stimulates the left ventricle, says Russell Bailey, MD, a practicing cardiologist with Mid Carolina Cardiology in Charlotte, N.C. The result is resynchro-nization of ventricular contractions and greater left ventricle efficiency.

For example, a cardiologist may determine that, despite optimal medical therapy, a 68-year-old man with underlying cardiomyopathy (425.4) and progressive congestive heart failure would benefit from biventricular pacing and recommend a system implant, Bailey says.

Use 33224 for Device Upgrades

When cardiologists add biventricular pacing capability which includes attaching a special adapter for the added left-ventricular lead to existing pacemakers and implantable cardioverter-defibrillators (ICDs), coders should report 33224, which is a stand-alone code specifically developed for such pacemaker system overhauls.

New text inserted in CPT 2003's introduction to the pacemaker section states that in certain circumstances, "an additional electrode may be required to achieve pacing of the left ventricle (biventricular pacing)." In these situations, "transvenous (cardiac vein) placement of the electrode should be separately reported using code 33224 or 33225," according to CPT.

Report 33224 only when adding a new left ventricular lead to an old system, Melnick stresses. Indeed, the code description includes the term "previously placed pacemaker or pacing cardioverter-defibrillator pulse generator." The term "previously placed" is crucial because this clarifies that this is a system the patient already has, and what the physician is doing is converting it to a biventricular system, says Brian Outland, CPC, CCS, coding and reimbursement specialist with NASPE

Use 33224 when the physician takes out the existing generator, attaches the Y-adapter for the left ventricular electrode and reinserts the same generator, Outland says.

In addition, 33224 includes any necessary skin-pocket revision, as well as any services the physician performs on the previously implanted generator, including removing the generator, adding the special Y-adapter and reinserting the same generator. So you should not bill separately for these services.

Indeed, the procedure report should specify that the physician replaced the same generator, Outland says. Now, the parenthetical notes to 33224 and 33226 contain the phrase "replacement of generator" without specifying that this is the previously placed generator.

The work described by these codes relates to replacement of the old generator in the skin pocket, as opposed to replacement of the old generator with a new one, coding experts confirm. Outland says NASPE is hoping the AMA will change the description of 33224 to state "removal or replacement of the same generator" so this distinction is clear.

Additionally, you should report 71090-26 (Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation; professional component) with 33224 for fluoroscopic guidance used during the attached left ventricular lead insertion.

Outland and other coding consultants say the increased availability of new biventricular systems may eventually eliminate the need for device upgrades. Now, less than 5 percent of biventricular implant procedures include Y-adapter attachments.

Apply 33226 When Moving Leads

When a left ventricular lead dislodges or needs repositioning, you should apply 33226 (Repositioning of previously implanted cardiac venous system [left ventricular] electrode [including removal, insertion and/or replacement of generator]).

Report 33226 if a previously implanted left ventricular lead needs repositioning, regardless of how many days have passed since the initial insertion, according to the AMA's CPT Changes 2003: An Insider's View.

Repositioning a left ventricular lead is a more labor-intensive procedure than moving right atrial or right ventricular leads. The physician cannot place the lead directly into the left ventricle but must navigate through the coronary sinus and place the lead in a coronary vein branch, so you should report 33226 to capture the extra work the procedure requires.

NASPE argues that the relative value units for placing or repositioning a left ventricular lead should not be insignificant because the procedure can be difficult, Melnick says.

Note: For an overview of all the new cardiology codes for 2003, see the December 2002 Cardiology Coding Alert. To order a copy of the AMA's CPT Changes 2003: An Insider's View, call (800) 621-8335.