# PM Skin Pocket Revision?



## CardioCoder79 (Oct 3, 2018)

The pocket was only enlarged to fit the generator better. It was not relocated and it's not during a global period. 

Any ideas on what to bill?


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## twizzle (Oct 3, 2018)

*Pocket revision.*

So what procedure was performed?

The description you give does not constitute a pocket revision which is more accurately a pocket relocation.

The original pocket is closed and a new pocket created. Just making it a bit bigger to fit the generator is inclusive to the pacemaker procedure. I'm assuming your provider did a generator change or upgraded the system.


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## CardioCoder79 (Oct 4, 2018)

See the report below. The generator was changed out in June of 2017 so it's not a global situation. He simply made the pocket larger. 


HH Cardiac Cath
DATE OF SERVICE: 10/02/2018

Patient has a permanent pulse generator, which is protruding and causing discomfort.  There is concern due to the protrusion of the device under the skin that the patient is at increased risk for lead erosion.  The patient requests to have his pocket revised and is undergoing permanent pacemaker pocket revision at this time.  

Patient was taken to the Cath Lab and after the usual sterile prep and drape procedure of the left subclavian site, 1% Xylocaine was utilized and moderate sedation was provided.  I administered moderate sedation throughout this 66-minute procedure, start time 8:50 a.m. and end time 9:56 a.m.  An independent trained observer pushed medications at my direction and monitored the patient's level of consciousness and physiologic status throughout.  The wound was irrigated with triple antibiotic solution after an incision was made and carried down superficial to the existing pulse generator.  The patient's pocket was enlarged inferiorly using sharp dissection.  Adequate hemostasis was achieved and the pulse generator itself was sutured into place using a 2-0 silk.  Redundant lead was tacked down to the base of the pocket with 2-0 silk.  The subcutaneous tissue was closed using continuous 3-0 Vicryl.  The skin was closed using absorbable staples and two 3-0 Ethilon sutures.  Patient tolerated procedure well.  There were no complications.


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## cgaston (Oct 4, 2018)

I found this out on the web:

_When the procedure is a revision (as this one is), the physician is draining a hematoma, debriding scar tissue or an infection and/or enlarging the existing pocket for the pacemaker. In any case, the end result is that the physician is placing the generator back into the original pocket. The CPT manual directs you to select one of the following integumentary codes for the procedure, as appropriate: Incision and drainage (10140 and 10180) or debridement (11042, 11043, 11044, 11045, 11046 and 11047).
Note that a relocation, by contrast, involves opening the existing pocket, incising and draining any abscess or hematoma that is present, closing that pocket and creating a new pocket where the generator is then placed. The CPT manual directs you to report code 33222 for relocation of a pacemaker or 33223 for relocation of a defibrillator.

Check your payer’s policy for reporting wound closure with a debridement. Medicare, for example, doesn’t allow it for procedures with a global surgery indicator of 000, 010, 090 or MMM, except for certain cases such as Moh’s surgery or excision of malignant lesions and benign lesions greater than 0.5 cm. Code 11042 has a 000 global period, so wound closure would not be separately billable, based on these rules. (Medicare National Correct Coding Policy Manual, Chapter 3).

If separate payment is permitted, the four-layer closure documented would likely fall under an intermediate closure. The surgeon does not document the size of the wound repaired, so you’d report code 12031 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [except hands and feet]; 2.5 cm or less).
_

So it looks like you should look in the Integumentary System codes. Hope it helps!


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## CardioCoder79 (Oct 4, 2018)

Thank you so much for the help! However, there is no hematoma or abcess. I don't feel comfortable using incision and drainage codes when there is no hematoma, seroma, bulla, cyst, or fluid present. And the debridement codes are based on the depth of tissue removed. He didn't remove anything. He only made the pocket bigger. 

I'm thinking it's not billable but I'm not giving up just yet! 

Any more suggestions?


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## CardioCoder79 (Oct 4, 2018)

I guess debridement is my best option. 11042


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## Cats3 (Oct 17, 2018)

*Answer?*

I am struggling with this same thing. Patient had a pocket erosion and the doctor only expanded the pocket subpectorally. I am still unsure what CPT code to use as there was no infection or hematoma or anything. Have you gotten paid for the 11042 that you used?

Thanks,
Laura


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## CardioCoder79 (Oct 18, 2018)

I wasn't comfortable billing the 11042. I used unlisted code 17999. It was my only option really.  We haven't received any correspondence back yet. I'm quite sure they will request records before processing.


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