Cardiology Coding Alert

See how to code lead repair and battery change at same session.

Coding for electrode repair is a little clearer in 2012.

In 2011, your electrode (lead) repair options for a pacemaker (PM) or implantable cardioverter-defibrillator (ICD) included these two codes:

• 33218, Repair of single transvenous electrode for a single chamber permanent pacemaker or single chamber pacing cardioverter-defibrillator
• 33220, Repair of 2 transvenous electrodes for a dual chamber permanent pacemaker or dual chamber pacing cardioverter-defibrillator.

You might see electrode repair for problems like insulation breaks, explained Vicki Pappas, CPC, in her December 2011 presentation "It's Electrifying....EP Coding 2012 Updates" (www.codingconferences.com).

Problem: Based on the wording in the 2011 definitions, neither code seemed appropriate for repair of a single lead in a dual-chamber system. Code 33218 referred to a single lead in a single-chamber system, and 33220 referred to repairing two leads in a dual-chamber system. At one point, AMA's Principles of CPT® Coding (fourth edition) recommended reporting 33220-52 (Reduced services) to represent repair of a single electrode in a dual-chamber device.

2012 solution: CPT® 2012 revises the code definitions to refer only to the number of electrodes and not the number of chambers involved:

• 33218, Repair of single transvenous electrode, permanent pacemaker or pacing cardioverter-defibrillator
• 33220, Repair of 2 transvenous electrodes, permanent pacemaker or pacing cardioverter-defibrillator.

Based on these definitions, the appropriate code for single-electrode repair when the date of service is on or after Jan. 1, 2012, appears to be 33218.

Battery Change + Lead Repair = Multiple Codes

Due to changes elsewhere in the PM and ICD range of CPT®, the codes you'll pair with 33218 and 33220 for lead repair at the same session as a battery change have a new look.›› ››

A note with 33218 instructs that when the physician repairs a single electrode for a PM or ICD at the same session as pulse generator replacement, you should report 33218 with the appropriate code from:

• 33227-33229, Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator...
• 33262-33264, Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator ...

Code 33220 has its own new note instructing you to report repair of two transvenous electrodes and generator replacement at the same session using 33220 in conjunction with the single appropriate code from:

• 33228 (dual lead PM battery change)
• 33229 (multiple lead PM battery change)
• 33263 (dual lead ICD battery change)
• 33264 (multiple lead ICD battery change).

As a contrasting example, for single-chamber PM electrode repair and battery change in 2011, you would have reported 33218 for the repair, 33233 (2011 definition: Removal of permanent pacemaker pulse generator) for removing the old battery, and 33212 (Insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular) for inserting the new battery.

Snag: Correct Coding Initiative (CCI) version 18.0 shows edits bundling dual- and multiple-lead PM battery changes (33228-33229) with single lead repair code 33218. The edits have a modifier indicator of 0, so you may not override the edits. The edits could cause reporting problems if the physician repairs a single lead at the same session as a battery change for a dual- or multiple-lead system. Despite the edit, some experts recommend reporting the appropriate codes for the service (such as 33228 and 33218). If the payer denies one of the procedures, then after you receive the initial reimbursement, you should appeal the denied procedure and request reimbursement for it. We'll keep you posted on whether the edit changes.

Fortunately, you may not see battery change with lead repair too often. You may be more likely to see an existing fractured lead capped and a new lead implanted (rather than seeing repair), says Christina Neighbors, MA, CPC, CCC, ACS-CA, charge capture reconciliation specialist and coder at St. Joseph Heart & Vascular Center in Tacoma, Wash. As an example of how to code in that situation, suppose the cardiologist performs a dual-chamber PM generator change, caps the previously present right atrial lead, and then places a new right atrial lead. You should report 33233 (2012 definition: Removal of permanent pacemaker pulse generator only) and 33206 (Insertion of new or replacement of permanent pacemaker with transvenous electrode[s]; atrial).

Helpful Hint: Here's When Fluoro Code Applies

One last important change to lead repair coding is that you should not report a separate guidance code. Under CPT® 2012 guidelines, radiological supervision and imaging (RS&I) is included in 33206-33249.

Opportunity: In those instances where the physician uses fluoroscopic guidance for diagnostic lead evaluation, but he does not perform a lead insertion, replacement, or revision, you should report 76000 (Fluoroscopy [separate procedure], up to 1 hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]), as stated in the Cardiology Services Update by Kenneth P. Brin, MD, PhD, FACC, of the CPT® Editorial Panel, and James Blankenship, MD, MACC, FSCAI, of the Relative Value Update Committee, at the CPT® and RBRVS 2012 Annual Symposium.

You'll find this important instruction in the CPT® 2012 guidelines, as well.