Cardiology Coding Alert

Tack on 33225 for New Left Ventricular Leads

Published on Wed Jan 01, 2003

If the cardiologist is putting in a totally new biventricular system, regardless of whether it's a pacemaker or a defibrillator, you should report the base codes for device insertion and add +33225 (Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator [including upgrade to dual-chamber system] [list separately in addition to code for primary procedure]).

Don't forget to add this new code, because you could lose out on reimbursement for the left ventricular lead insertion if you overlook it.

Since CPT 2003 approved 33225 as an add-on code, which indicates recognition of the specific, additional work involved in inserting new devices with left ventricular leads, coding experts hope payers will recognize this.

Medicare and private payers have provided solid coverage for new biventricular device implantation since the U.S. Food and Drug Administration's (FDA) approval of the InSync biventricular pacing system in 2001, says Barbara Veath, senior reimbursement manager for heart failure products with Medtronic Inc. in Minneapolis.

Some carriers are used to seeing the unlisted-procedure code for cardiology (33999) for left ventricular lead placement and may not recognize 33225. So coders may initially have to explain that this is a new, unique code for what was an unspecified procedure last year, Veath says. Even so, payers would be more likely to deny payment for upgrades with the Y-adapter (33224) than 33225 because the new biventricular devices have FDA approval, she adds.

As with other biventricular procedures, physicians need to be very specific about describing in their procedure notes that they inserted and attached the left ventricular lead, or they could risk losing substantial reimbursement, Veath emphasizes.

Third Lead Is Crucial in Dual-Chamber Pacers

When the new system is a dual-chamber pacemaker, report 33208 (Insertion or replacement of permanent pacemaker with transvenous electrode[s]; atrial and ventricular) plus 33225 for placing the left ventricular lead, and 71090-26 (Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation; professional component) for the fluoroscopic guidance, says Jim Collins, CHCC, CPC, president of Compliant MD Inc. in Matthews, N.C., and compliance manager of multiple cardiology groups in the Charlotte, N.C., area.

For insertions of new ICDs, report 33249 (Insertion or repositioning of electrode lead[s] for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator) and 93641 (Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads ... with testing of single or dual chamber pacing cardioverter-defibrillator pulse generator), plus 33225 for left ventricular lead insertion and 71090-26 for the fluoro-scopic guidance used to place the lead.

When the cardiologist removes an old pacemaker, implants a new generator and inserts a left ventricular lead, you should report 33233 (Removal of permanent pacemaker pulse generator), 33213 (Insertion or replacement of pacemaker pulse generator only; dual chamber), 71090-26 and 33225. In other words, if a physician removes an old system and replaces it with a new one, you should charge for the removal of the old system, Collins says.

Like 33224, 33225 includes venography, so you would not report that separately, Collins says.

According to parenthetical information accompanying the 33225 description, you should use this code with the following primary pacemaker procedure codes: 33206-33208, 33212-33214, 33216-33217, 33222, 33233-33235, 33240 and 33249.

The AMA will likely delete 33206 (Insertion or replacement of permanent pacemaker with transvenous electrode[s]; atrial) from the list of codes that 33225 can be added to, Collins predicts. Code 33206 involves implanting a single-chamber pacemaker with an atrial lead. If you add a biventricular lead to it, you won't have biventricular pacing because you're pacing the right atrium of the heart and the left ventricle but not both ventricles, he says.

If the physician implants a new generator and adds a Y-adapter to achieve biventricular pacing, report the procedure as you would in the absence of the left ventricular lead, and then add on 33225. This logic holds true for all new generator implantations, Collins says.