Cardiology Coding Alert

How to Code Correctly for Pacemaker Insertion and Removal

Proper coding tactics can overcome the main hassles in pacemaker billing, our experts say. Although coding for generator removal or replacement is essentially straightforward, when the cardiologist removes or replaces leads, coding becomes more complex, and being paid for the additional time necessary also becomes a factor.
The pacemaker comprises two basic componentsthe generator and the leads, which are the wires attached to the generator that go into the heart muscle. CPT lists a number of codes both for generator and lead removal and/or replacement. For instance, 33233 (removal of permanent pacemaker pulse generator) is used when the generator is removed but the leads remain, while 33212 (insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular) or 33213 (dual chamber) is the appropriate code when replacing the device. These codes should be used only when all the cardiologist does is open the skin pocket created for the pacemaker, remove the old generator and/or replace it.
Corrective Procedures are Reimbursable

Pacemaker insertion is considered major surgery and has a 90-day global period.

Sometimes the patient may dislodge one or more of the leads on the pacemaker, or the lead itself may be faulty or connected incorrectly. In those situations, the cardiologist must go back and reposition the lead. Such corrective procedures are reimbursable despite the 90-day global period; however, the specific code used in such situations varies by time, depending on whether the problem with the lead is corrected more or less than 15 days after the insertion of the pacemaker.
Denise Reckers, CRT, a respiratory therapist and a coder with Cardiology Consultants, a group practice with eight cardiologists in Abilene, TX, says there are two different kinds of pacemakerssingle and dual chamber. Single-chamber pacemakers are referred to as VVIs or AAIs, depending on whether the lead is attached to the atrium or the ventricle, while the dual-chamber pacer is commonly called a DDD.
When the cardiologist inserts a new VVI or AAI, the procedure is billed with CPT code 33207(insertion or replacement of permanent pacemaker with transvenous electrode[s]; ventricular) or 33206 (atrial). Inserting a DDD, meanwhile, is billed with 33208 (insertion or replacement of permanent pacemaker with transvenous electrode[s]; atrial and ventricular).
If the lead malfunction is corrected more than 15 days after a VVI or AAI pacemaker was installed, the procedure should be coded 33218 (repair of pacemaker electrode[s] only; single chamber, atrial or ventricular). A DDD pacemaker lead repair performed before the 15-day threshold would be billed with 33220 (dual chamber). If the repair takes place more than 15 days after the pacemaker was inserted, use code 33216 (insertion, replacement or repositioning of permanent transvenous electrode[s] only [15 days or more after initial insertion]; single chamber, atrial or ventricular) for the VV1 or AAI, while the same procedure for a DDD should be charged with 33217 (dual chamber).
The diagnosis code for these procedures would be 996.01 (mechanical complication of cardiac device, implant, and graft;due to cardiac pacemaker [electrode]), Reckers says. Rebecca Sanzone, CPC, assistant billing manager with Mid-Atlantic Cardiovascular Associates, a 46-cardiologist group practice in Baltimore, MD, adds that there also is a V-code (V45.01, cardiac device in situ; cardiac pacemaker) that may be used.
Tips on Coding Typical Pacemaker Problems
Sanzone notes that guidelines issued by the American College of Cardiology state that CPT imaging code 71090(insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation) should not be billed because it is included in the pacemaker insertion codes mentioned above. According to Sanzone, Medicare and some private payers still pay for the imaging; however, she expects that Medicare will bundle the procedure into the primary pacemaker code soon. Reckers, although aware of the ACC guideline, says her practice bills for imaging and gets paid. As always, cardiologists should check with their payers to determine the specific policies in this area.
Note: The diagnosis codes used for these procedures are 426.x (conduction disorders) and 427.x (cardiac dysrhythmias).
Sanzone points out that portions of the leads sometimes break off and need to be removed, but cardiology practices often overlook billing for the removal of these foreign bodies. The correct code is 37203 (transcatheter retrieval, percutaneous, of intravascular foreign body [e.g., fractured venous or arterial catheter]). The code should be billed in conjunction with the imaging procedure used to locate the missing piece of lead, such as a fluoroscope.
Some coders also try to bill for an imaging code, such as the 71090, when the cardiologist removes or replaces a generator. But using imaging codes in these situations is inappropriate, Reckers explains, because for these procedures there is nothing requiring imaging. All the cardiologist has done is opened the skin pocket, removed and/or replaced the old generator, and rehooked the leads.
She also notes that generators and leads are bundled by Medicare, meaning you can charge only for one or the other. The question then becomes, which procedure should be coded? That, according to Reckers, depends on what the cardiologist did, so its important to talk with the physician and read the operative report from top to bottom (which is always a good idea anyway).
If the physician removes and replaces the generator on an end-of-life pacemaker and also inserts new leads but does not remove the old leads (which are embedded in the heart muscle and must be taken out by a cardiovascular surgeon, although, in rare cases, a cardiologist may remove them), then the procedure should be billed as insertion of a new pacemaker (33206-33208, depending on whether the pacemaker was AAI, VVI or DDD), because both the generator and leads (the two components of the pacemaker) have been replaced at the same time.
But if a patient with a history of complete heart block requires only a generator replacement for the same end-of-life VVI pacemaker, the cardiologist will remove the old generator, put a new one in and reconnect the leads. That procedure should be coded as removal of generator (33233) and replacement of generator (33212).
Pocket Procedures Must be Done Separately
Also, sometimes the pocket created to house the pacemaker is faulty or becomes infected. Although CPT has a code for repairing the pocket (33222, revision or relocation of skin pocket for pacemaker), this code is never paid if the procedure is performed in conjunction with any work on the pacemaker, generator or leads. Theoretically, though, the pocket revision could be billed if it was performed on its own with no work done to the pacemaker, generator or leads.
Finally, it is important to note that when performing any of these procedures, the cardiologist cannot charge for admitting a patient or any other E/M service unless the patient also presents with a totally different problem, in which case the E/M would be billed appended with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).