Upgrade to ICD help


Green Bay
Best answers
Okay, I got my first electrophysiologist this month and I'm learning here. Please help me with the following procedure note:

1. Left upper extremity venogram.
2. Removal of the patient's pacemaker pulse generator.
3. Placement of an ICD lead.
4. Placement of an ICD pulse generator.
5. DFT testing of an ICD lead system.

1. Ischemic cardiomyopathy.
2. Severe LV dysfunction.
3. Pacemaker in situ.

1. Ischemic cardiomyopathy.
2. Severe LV dysfunction.
3. Pacemaker in situ.

ANESTHESIA: Local Lidocaine and moderate sedation with intravenous Versed and Fentanyl.



SPECIMENS: The patient's prior pulse generator was removed from the field.

INDICATION FOR PROCEDURE: The patient is an 81-year-old man with ischemic cardiomyopathy and severe LV dysfunction who recently had a syncopal episode and found to have VT on his pacemaker. He has been wearing a life vest since then. He is referred for upgrade of his device to an ICD system. A transthoracic echo with contrast ruled out LV thrombus prior to this procedure.

DESCRIPTION OF PROCEDURE: The indication, risk, benefits, alternatives, and details of the procedures were discussed with the patient, and he provided informed written consent. The patient was brought to the electrophysiology laboratory where he was prepped and draped in the usual sterile fashion.

Left upper extremity venography was performed which confirmed a patent left subclavian system.

Lidocaine was used to anesthetize the left pectoral region over the prior device implantation scar. Using a scalpel, a 4 cm incision was made over the prior scar. Using blunt dissection and brief bursts of electrocautery, the device and leads assembly were freed from their adhesions.

The pulse generator was then disconnected from the leads with the appropriate torque wrench. The leads were inspected and found to be intact. They were tested and found to have appropriate sensing, threshold, and impedance values.

Using the venogram as a guide, left subclavian venous access was then obtained using an introducer needle. A wire was placed and a 9-French sheath. The ICD lead was then delivered to the septum, proximal to the apex, using fluoroscopic guidance. Multiple locations were checked in order to find appropriate threshold and impedance values. This is likely due to the patient's anteroseptal aneurysm.

Once appropriate sensing, threshold, and impedance values were obtained, the sheath was split and removed. The lead was then secured to the underlying tissue with 0 silk x2. The patient's existing leads were also retested and found to be intact. They were dissected down to the Silastic colors which were then resecured with 0 silk x2 each.

The pocket was then irrigated with copious Bacitracin and saline solution.

The pulse generator was then connected to the leads with the appropriate torque wrench. The device and leads assembly was then placed in the cleaned pocket. Given the patient's appropriate parameters on the existing RV pacing lead, this was used for the rate sense portion of the ICD. The rate sense functionality of the new ICD lead was capped. The pulse generator was then secured to the underlying tissue with 0-silk x 1.

The patient was then fully sedated for DFT testing. Shock on T induced VF which was appropriately detected with no dropout. A 16-joule shock successfully restored sinus rhythm. The patient's DFT is therefore considered to be less than or equal to 16 joules.

The wound was then closed in 3 layers with 2-0, 3-0, and 4-0 absorbable suture material in the fascial, subcutaneous, and subcuticular layers, respectively. Steri-Strips and a Tegaderm dressing as well as a pressure dressing were applied.

The patient tolerated the procedure well, was then transferred to his monitored bed in stable condition.

IMPLANTED HARDWARE: Pulse generator is a Medtronic D334DRG, serial number is PSP200542H. The ICD lead is a Medtronic 6935, serial number TAU106869V. The existing RA lead is a Medtronic 4076, serial number BBL167471V, was implanted 4/25/07. The existing RV lead which is used as the rate sense lead is a Medtronic 4076, serial number BBL193687V, implanted 4/25/07.

EXPLANTED HARDWARE: The pulse generator is a Medtronic VEDRO1, serial number PWH211947H, had been implanted 4/25/07.

LEAD PARAMETERS: RA lead senses 6.1 mV, threshold 0.3 V at 0.5 msec, impedance is 385 ohms. The ICD lead senses 8.6 mV, threshold 0.7 V at 0.5 msec, impedance 695 ohms. The chronic RV rate-sense pacing lead senses greater than 30 mV, threshold 0.5 V at 0.5 msec, impedance 548 ohms. The high-voltage impedance is 60 ohms.

The device is programmed AAIR-DDDR 60-120, paced AV delay 180, sensed AV delay 150. The VT zone is set at 188 beats per minute with 1 burst, 1 ramp, and max joule shock. The VF zone is set to 214 beats per minute with 35 joules x6.

Please note that the patient's prior pacing lead is connected for the patient's rate-sense functionality of the ICD. The ICD lead rate sense functionality is capped.

I have:
33233 for removal of PM generator
33249 for insertion of ICD lead and generator

I need help with the rest.
1) Is 93641-26 the appropriate testing code? I see the leads being tested but not sure about the generator.
2) Provider circled on his route 33216 but I imagine that isn't correct because the ICD lead being inserted is included in the 33249.
3) Provider also circled 33223 for revision of ICD skin pocket. Is that correct?

Jessica CPC, CCC


True Blue
Ballina, Mayo County
Best answers
ICD billing

You have the correct codes with 33249 and 33233.
33216 and pocket revision are inappropriate. He makes no mention of revision in the report and 33249 covers insertion of ICD and lead(s).... revision is only billable if the revision is extensive and even then it can be difficult to get it paid. You need to use modifier -59 whatever.
Testing of the device is 93641-26(P). 93640 is hardly ever used, even if just leads are placed, as you are still effectively testing the whole system.
Venography cannot be billed as it is considered roadmapping. Sometimes my providers will do a venogram if there is extreme difficulty placing a lead. I think the Dx code is 459.2 but you cannot bill venography with placement of a LV lead as it is bundled.
Hope this helps.