Wiki Semi- temporary pacemaker

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deeva456

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How would you code this? I coded it as 33210 but the EP physician is asking to bill with 33216. The electrophysiologist "was told" by other EP physicians to bill with 33216. However the lead was connected to an external PM generator. The patient will be wearing this for more than 2 weeks while waiting for an infection to clear up.


Preoperative diagnosis / indication: Complete heart block in shock status

Postoperative diagnosis: The same as above with successful device implant
Procedure:
· Sedation by anesthesiologist.
· Semi-permanent pacemaker implant, transvenous, right jugular vein, with right ventricular lead, 33216.
· Fluoroscopy

Consent:
Informed consent was obtained (see my clinical notes for details).

Methods:
· Pre-procedure
Patient was brought to EP suite and placed onto the procedure table and monitored for blood pressure, EKG tracings, and pulse oximetry in a routine way. Transcutaneous pacing and defibrillation pads were set up in a routine way.
Prophylactic antibiotic: ancef. . The neck was prepared with sterile techniques. Sedation was initiated.

· Device implant
The patient had asystole requiring transcutaneous pacing during part of the procedure.
The patient was draped in a sterile fashion. Access to the right jugular vein was obtained using a modified Seldinger technique with US. guidance. RV lead was placed in the RV with active fixation through sheath, tested with appropriate parameters with no phrenic nerve or diaphragmatic stimulation using 10 V pacing, secured with sleeve to skin with 0 sutures at venous entry site, and attached to external pacemaker generator. The lead was also secured to skin with sterile tapes and dressings in a routine way. Post procedure fluoroscope showed normal heart wall motion.

· Post-implant
The patient tolerated the procedure well, with no immediate complications. The patient was transferred out for further observation and monitoring.
The patient received appropriate procedural sedation throughout the procedure. For medication and other details, please refer to nurse medication summary and nurse note.

Complications: no immediate EBL: < 10 ml Fluoroscope time: < 3 min
Medications: See nurse lot. Contrast: 0 ml

Summary: Successful implantation of semi-permanent pacemaker without acute complications.

Thank you
Dolores
 

I would code it as 33210. C Collison CPC, CCC. I found this on line from ECLAT Health Solutions:​

Example:​

TEMPORARY PACEMAKER INSERTION

This 70-year-old male with atrial fibrillation has been placed on a combination of digoxin, metoprolol, and Cardizem. Presenting to the Emergency Department, he was profoundly weak, near syncope. ECG showed atrial fibrillation with slow ventricular response in the 20s and 30s. Digoxin level was 2.9. Digibind was given in the Emergency Department. A slow ventricular rate in the 30s continued, and a decision was made to insert a temporary pacer wire.

The procedure was performed in the cardiac catheterization laboratory. Groins were prepped and
draped in the usual sterile fashion. After infiltration with lidocaine, the right femoral vein was entered via percutaneous technique without difficulty and a 6 French sheath was advanced over the guidewire. Balloon-tipped temporary pacer wire was advanced under fluoroscopy into the right ventricular apex. Threshold was less than 1mA. The patient tolerated the procedure well with no immediate complications. Temporary wire was set at 60 beats per minute with a current of 3mA. The patient was transferred out of the catheterization lab in stable condition. Cardizem and metoprolol were held.

When coding insertion of a temporary pacemaker (ventricular) in PCS (5A1213Z or 5A1223Z) there is no prompt to code also the lead. However, according to the Coding Handbook Chapter 27- Cardiac Pacemaker Therapy, there is a directive to, “plus the appropriate code for the lead insertion”.

A question was sent to AHA Coding Clinic yielding the following response,

“…In a temporary pacemaker insertion, leads are inserted via a catheter and
Click to expand...
attached to an external generator. This type of pacemaker is generally used for an acutely ill patient until a permanent pacemaker can be inserted. Temporary pacemaker procedures are classified to 5A1213Z or 5A1223Z …plus the appropriate code for the lead insertion.”
Click to expand...
In our example above, this patient did not have a permanent pacemaker inserted, and was medically managed. Adding the lead changed the DRG from a medical DRG to a surgical DRG with an increase in reimbursement.

Challenge: You may want to look at your data, pulling accounts with temporary pacers in medical DRGs to ensure the lead was assigned.​

 
Thank you for the information. I also sent this question to Dr. Z's publishing and here is their response.

My EP physician does a semi-permanent pacemaker implant. He says he was told to bill 33216, but the lead is attached to an external generator. Wouldn't this be 33210 (temporary pacemaker)? Here is his note:

"Semi-permanent pacemaker implant, transvenous, right jugular vein, with right ventricular lead (33216). The patient was draped in a sterile fashion. Access to the right jugular vein was obtained using a modified Seldinger technique with US guidance. RV lead was placed in the RV with active fixation through sheath, tested with appropriate parameters with no phrenic nerve or diaphragmatic stimulation using 10 V pacing, secured with sleeve to skin with 0 sutures at venous entry site, and attached to external pacemaker generator. The lead was also secured to skin with sterile tapes and dressings in a routine way. Post procedure fluoroscope showed normal heart wall motion."

A:

If during TAVR, it is not coded. The usual case is infection, and when they do an active fixated lead connected to an external generator, we do report as 33216. Since it is actively fixated and left for some period of time they call this sometimes a semi-permanent system. After the infection clears with antibiotics (it may be days) we report 33234 for removal of the active fixation lead and code for a new system if placed. -Dr. Dunn
 
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