Cardiology Coding Alert

Medicares national Correct Coding Initiative (CCI) bundles the insertion of a temporary pacemaker (33210, insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter [separate procedure]) to procedures such as percutaneous transluminal coronary angioplasties (PTCAs) (92982), stents (92980) or atherectomies (92995) when the insertion is performed during coronary interventions. In some circumstances, however, it may be appropriate to bill separately for the temporary pacemaker insertion.

In such cases, modifier -59 (distinct procedural service) should be attached to 33210, and, in the event of an audit, documentation must indicate why 33210 was separately billed, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C.

Temporary Pacemaker Use

The CCI edit that bundles 33210 to coronary interventions has existed for several years, explains Martha Gerant, CPC, a coder with Cardiology Services, an 11-physician practice in Shawnee Mission, Kan. When interventions were relatively new procedures, cardiologists anticipated there might be cardiac arrhythmia problems during the intervention, so the temporary pacer was installed, regardless of whether it was used, she says.

In the old days, temporary pacers were routinely installed before interventions because the interventions were new and risky and cardiologists werent as proficient as they are now in performing them. The cardiologist would do a femoral puncture stick first, install the lead wires (with the temporary generator placed outside the body) and then perform the intervention, Gerant says.

When using this technique, the patient may develop complications during the process of the intervention, such as cardiac arrest (427.5), severe bradycardia (427.89), second degree block (426.13) or Mobitz II atrioventricular block (426.12). When this occurred, the temporary pacemaker would help support the hearts function.

Gerant points out that installing temporary pacemakers for such backup purposes is no longer standard procedure for cardiologists. Sometimes, however, a patient may develop a serious problem during or after an intervention, such as complete heart block (426.0). In such cases, a temporary pacer will be inserted to treat the life-threatening arrhythmia.

How to Get Temporary Pacemaker Payment

Although the CCI edit is still in effect, the insertion of the temporary pacer in this situation is payable, but only if modifier -59 is appended to the 33210 and documentation that justifies the need for temporary pacing separate from the intervention is sent along with the claim, according to the American College of Cardiology (ACC).

Medicodes Coding Illustrated Cardiovascular and Respiratory concurs, stating: When performed alone or with other unrelated procedures/services, [33210] may be reported. If performed alone, list the code; if performed with other unrelated procedures/services, list the code and append modifier -59.

Using modifier -59 overrides the edit and prevents outright rejection of the claim by Medicare and most other carriers. But, the documentation needs to indicate that the temporary pacer was not already in place as a backup, notes Gerant.

The fluoroscopy code for a temporary pacer insertion (71090, insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation) may also be billed, Gerant says.

Because the Healthcare Financing Administration (HCFA) considers temporary pacemaker placement to be a part of any of the three coronary interventions, if the claim for 33210 is submitted without modifier -59, it will be rejected because the carrier will assume incorrectly that all the services were performed as part of one procedure.

The CCI lists 33210 as a component of the larger procedures 92980, 92982 and 92995. Such edits are listed in the CCI as follows: The comprehensive (primary) code is listed on the left of each column. To the right of each comprehensive code is a list of those component codes bundled with it. CCI further includes either the number 0 or 1 on the top right of the component code. If a 0 appears, then even modifier -59 will be unable to override the edit. But when 33210 appears as a component of 92980, 92982 and 92995 it includes a 1 indicator, which means modifier -59 may be appended to the code if the procedure was truly distinct.

Because the temporary pacer insertion is a different procedure or surgery, the temporary pacemaker was not inserted prophylactically (i.e., as a preventive measure), but rather because the heart block occurred during or after the intervention. Therefore, it meets one of the criteria listed in CPT 2000 for using modifier -59, which may be correctly used to bill for the insertion.

In such a case, the documentation must indicate that a pacer was not inserted before the session started and that it was placed when the patient developed symptoms during the intervention. If the pacer was already there when the symptoms occurred, 33210 should not be billed, Callaway-Stradley says.