# Pacemaker gen change with failed lead replacement



## jenneverett (Jul 22, 2015)

Hello All!
I am stuck on this one: After much manipulation the new lead could not be placed. What I think the codes should be are at the bottom. Thanks for any thoughts!

PROCEDURE PERFORMED:
1. Dual chamber permanent pacemaker generator change.
2. Attempted RV lead placement.
INDICATION FOR PROCEDURES: End of battery life status.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: The patient was brought to the Cath Lab after informed and signed consent was obtained. The left subclavian area was draped and prepped in a sterile surgical fashion. The patient received IV antibiotics per protocol. The left subclavian artery was
infiltrated with 2% Xylocaine with epinephrine with careful dissection to avoid any trauma to the exiting leads and existing device, the pocket was opened and the device was removed from the pocket. Vascular access was then obtained with a long introducer sheath to overcome a stenosis in the left subclavian vein. A right ventricular lead was placed despite extensive
mapping in 7 or 8 different positions. We were not able to obtain pacing and sensing thresholds any better than the existing right ventricular lead. After an exhaustive amount of time finding a reasonable pacing sensing site, the decision was made to remove the new lead, connect the device to the old lead and the prior atrial lead, as well. The device was placed
in the pocket after the pocket was extended to accommodate the larger device. The pocket was then closed in a 3-layered fashion, with excellent hemostasis and wound approximation.
MATERIALS USED:
1. The new device implant is a Boston Scientific Accolade DR. Model number is L301, serial number is 703556.
2. The existing right atrial lead is a Biotronik device/lead. The model number is 343081, serial number is 24043972.
3. The right ventricular lead is a Biotronik model number 343081, serial number is 24124853.
INITIAL MEASURED DATA:
1. The right atrial T-wave sensing is 2.6 millivolts with a pacing threshold of 0.7 at 0.4 msec with a lead resistance of 451 ohms at a current of 1.6 milliamps.
2. The right atrial R-wave sensing cannot be obtained due to 100% pacemaker dependent. The pacing threshold was 1.8 volts at 0.4 milliseconds with a lead impedance of 403 ohms.
INITIAL PROGRAM PARAMETERS: The device is programmed in a DDDR mode with a lower rate limit of 70, upper rate limit of 130.
CONCLUSIONS:
1. A dual chamber permanent pacemaker generator change. Note that a right ventricular lead was attempted to be placed but could not find acceptable pacing thresholds that were any better than the existing right ventricular lead. Note the new device which has autocapture. The estimated duration of the battery status on this device will be approximately 7 years.
2. The patient will be admitted to the hospital for further observation and evaluation. I will anticipate discharge to home tomorrow morning.

33233
33234
33208
33225-52 

or

33228
33225-52

Jennifer Everett, CPC


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## twizzle (Jul 23, 2015)

*Pacemaker*

Several issues here. 
1) The report states "a right ventricular lead was placed despite extensive mapping etc.". Shouldn't that be "was not placed"?
2) If you were going to bill anything pertinent to the lead replacement, what diagnosis would you use?
3) You cannot bill for insertion and removal of a lead that was never placed.
4) Why would you bill 33225 when no mention is made of anything to do with A LV lead?

Billing 33208-52 would be the only way to capture insertion of a dual pacer generator with some work on lead placement (that ultimately was unsuccessful regarding the lead). This, along with 33233 is probably the way to bill this but you don't have a payable diagnosis for 33208. You would need your provider to document why the patient needs a pacer as V53.31(generator end of life) won't work. The ideal way to bill would be 33228 and 33216 but they cannot be billed together.

Hope this helps


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## jenneverett (Jul 24, 2015)

*Pacemaker follow up*

1. He placed it but could not get the sensing so he removed it.
2. the dx I would use is 996.09, because of the complication of the lead not doing what it should.
3. I misread the CPT book... I went back and forth between a couple of resources and misread... that's why I posted it here for help.  

The pacemaker was placed originally in 2004 for Sick sinus 427.81, an acceptable dx for Medicare. I do have that documentation from when the patient established with my doctor. 

Thanks for the help.

Jennifer


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## twizzle (Jul 24, 2015)

jenneverett said:


> 1. He placed it but could not get the sensing so he removed it.
> 2. the dx I would use is 996.09, because of the complication of the lead not doing what it should.
> 3. I misread the CPT book... I went back and forth between a couple of resources and misread... that's why I posted it here for help.
> 
> ...



Removing a lead can be quite a difficult process when it has been in place for some time. You definitely cannot bill for the placement and then the removal when the lead has only been in for a few minutes.... he does not say why he intended to replace it.

You cannot pull diagnoses from previous encounters so you could not bill 427.81. If the charge was audited and the auditor looked at the report where would he find the diagnosis for medical necessity?
Nowhere does the report state why he wanted to put in a new lead. The only diagnosis is 'end of battery life status'. 

The provider really does need to document his pre- and post-op diagnoses.

I agree this is a weird one but I would still bill it as I suggested once the diagnoses are documented. If he said there was a problem with the lead such as 'non-capture', 33208 would be justified along with 996.01 (not 996.09 because that is for a device other than those listed in the 996.0x section) 427.81, and V53.31 once they were documented.


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## jenneverett (Jul 24, 2015)

Thank you for your help I will ask the provider for an amendment to the report and ask for the change in report structure.  

Jennifer


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