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Cardiology Coding Alert

Information Facilitates Coding of Pacemaker Surgery

Published on Fri Feb 01, 2002

Although CPT 2002 includes more than a dozen codes related to pacemaker implantation, replacement and removal, the coding process for these procedures can be made simpler with information on the type of pacemaker (single or dual chamber), the components (pulse generators or electrodes/leads) and the number of days that have passed since the initial implantation.
 
"You need good communication from the physician to determine these factors," says Rebecca Sanzone, CPC, billing manager with Mid-Atlantic Cardiovascular Associates, a 58-physician practice in Baltimore. "That means the cardiologist must let the coder know exactly what was done." From that information, she adds, the coder may still have to pick and choose among codes, because many pacemaker codes are components of other codes and may be included in a more comprehensive procedure.
 
Sanzone advises coders to ask cardiologists the following questions to make the process even simpler:
 
  • Was the procedure a revision or removal?
     
  • When was the original implantation?
     
  • What revisions were made?
     
  • Was anything done to the pocket?
     
  • What approach did the physician use? 

    • Removal, Insertion and Repair

    CPT 2002 covers procedures involving the components of a pacemaker, such as the pulse generator and electrodes (also referred to as leads), as well as the entire pacemaker itself.
     
    Pulse Generators. Removing and replacing pulse generators are the simplest of these procedures:
     
    Use 33233 (Removal of permanent pacemaker pulse generator) when a generator is removed.
     
    Use 33233 and either 33212 (Insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular) or 33213 ( dual chamber) when a generator is replaced.
     
    Note: The "replacement" procedure noted in 33212 and 33213 does not cover removal of an old generator but merely the insertion of a new generator, which is why the removal code (33233) should be billed with the replacement code.
     
    Electrodes/Leads. Electrodes/leads are considerably more difficult to remove, insert, reposition, replace and repair than generators because they are placed on the heart chamber walls rather than in a pocket away from the heart.
     
    To report removal only, use 33234 (Removal of transvenous pacemaker electrode[s]; single lead system, atrial or ventricular) or 33235 ( dual lead system).
     
    To report insertion, repositioning or replacement, use 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) or 33217 ( dual chamber [two electrodes] permanent pacemaker or dual chamber pacing cardioverter-defibrillator).
     
    To report repair (as opposed to replacement), use 33218 (Repair of single transvenous electrode for a single chamber, permanent pacemaker or single chamber pacing cardioverter-defibrillator) or 33220 (Repair of two transvenous electrodes for a dual chamber permanent pacemaker or dual chamber pacing cardioverter-defibrillator).
     
    Entire Pacemaker. CPT includes codes that are used when the entire pacemaker (generator and electrodes/leads) is implanted or replaced: 33206 (Insertion or replacement of permanent pacemaker with transvenous electrode[s]; atrial), 33207 ( ventricular) and 33208 ( atrial and ventricular).
     
    Electrodes/leads can be difficult to remove because they are embedded in the heart muscle. The cardiologist may use a variety of techniques, such as contraction sheaths or laser-assisted extraction, or a cardiac surgeon may be called in to perform open-heart surgery to remove electrodes/leads. Sometimes, an old generator is removed and replaced and new electrodes/leads are implanted without removal of the old electrodes/leads. In such cases, the procedure should be reported as 33206 or 33207 (for a single-chamber pacemaker), or 33208 (for a dual-chamber) because both generator and electrodes/leads have been replaced. If the cardiologist does not have to insert new electrodes/leads but simply removes the old generator, places a new one and reconnects the electrodes/leads, the procedure should be reported as a removal (33233) and replacement (33212 or 33213) of generator.

    Upgrade to Dual-Chamber Pacemaker

    A patient with a single-chamber (atrial) pacemaker who develops atrioventricular node disease may require an upgrade to a dual-chamber (atrial and ventricular) pacemaker, which usually involves removing the existing pulse generator and replacing it with a dual-chamber generator, inserting a ventricular electrode/lead and checking the atrial electrode/lead. This procedure is reported as 33214 (Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system [includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator]).
     
    In some cases, the interrogation of the pacemaker reveals that the atrial electrode/lead must be replaced because the capture threshold on the electrode/lead is poor. Although physicians have been using the following strategies to code this scenario, it is important to ask your carrier for its policies on the issue when developing a billing strategy: 

     
  • Bill 33214 only. Proponents of this approach argue that 33214 includes not only the testing of the existing (atrial) electrode/lead but also the replacement and retesting of a defective electrode/lead. They note that all the other services provided, including the replacement of the pulse generator and the insertion of a ventricular electrode/lead, are included in 33214. Others note that removing the atrial electrode/lead, which typically is screwed in, can be difficult, so cardiologists should be paid more than for a typical upgrade, when the atrial electrode/lead is checked only. Furthermore, notes Anne Karl, RHIA, CPC, CCS-P, a coding and compliance specialist at St. Paul Heart Clinic, a 27-cardiologist clinic affiliated with United Hospital in St. Paul, Minn., 33214's descriptor refers only to the insertion of a new electrode/ lead and not electrodes/leads, which applies to the new ventricular electrode/lead being added and not the atrial electrode/lead being replaced.

     
  • It has been suggested that in addition to 33214, 33216 (used to report the insertion of a single electrode/lead) should be reported with modifier -59 (Distinct procedural service) appended. There are two serious problems with this approach. First, CPT 2002 specifically instructs physicians not to bill 33216 or 33217 in conjunction with 33214 (and appending modifier -59 is unlikely to work because this modifier is used to override Correct Coding Initiative edits and not CPT 2002 instructions). Second, CPT instructs cardiologists to use 33216 a total of 15 or more days after the initial implantation. Since the implantation and the replacement of the atrial electrode/lead occur on the same day, it is unlikely carriers will accept 33216 in this scenario.

     
  • Because carriers are unlikely to pay for 33214 and 33216 billed together, it may be necessary to dispense with 33214 and 33216 and break out the upgrade into its component parts, Karl says. "We break the session out to a generator removal (33233), a lead removal (33234) and the placement of a dual system (33208)," she says, "and we have not had difficulty obtaining reimbursement."

    • Related Repair and Guidance Procedures

    Pockets. The generator is housed in a pocket that sometimes needs repair. Although the CPT code for pocket repair 33222 (Revision or relocation of skin pocket for pacemaker) is bundled with all other pacemaker work, Sanzone says that 33222 can be billed on its own in rare instances when the repair is performed on its own. 
     
    Fluoroscopy. When a pacemaker or a pacer electrode/lead is placed under fluoroscopic guidance, 71090 (Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation) may be reported with modifier -26 (Professional component) appended. A local medical review policy from Wisconsin Physicians Service (the Medicare carrier in Illinois, Michigan, Minnesota and Wisconsin) states, "If fluoroscopy is used during the procedure, the radiological supervision and interpretation is a covered service using  71090. The use of fluoroscopy should be indicated in the operative report." This code should not be used when only a generator is removed or replaced. In such cases, there is nothing to image, as the cardiologist has simply opened a skin pocket, replaced a generator and rehooked the electrodes/leads.

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