# HELP w/ EP case



## Jess1125 (Feb 3, 2014)

I have a case that I knew would come back to haunt me and it indeed did. Please help me with what is the correct billing. Sorry, this may be lengthy but I have questions!

INDICATIONS FOR SURGERY:  The patient is a 61-year-old woman with a history of cardiac arrest and nonischemic cardiomyopathy with dual-chamber ICD in situ.  Her right atrial lead has had noise and has been turned off for several years.  She has now reached ERI.  She is now admitted with an appropriate shock for VT/VF.  The patient has now had 2 recent appropriate shocks for ventricular arrhythmias and will be starting on Amiodarone.  Given her baseline sinus bradycardia in the 50s, revision of the right atrial lead is planned in addition to the pulse generator change.


DESCRIPTION OF PROCEDURE:  The indications, risks, benefits, alternatives, and details of the procedure were discussed with the patient, and she provided informed written consent.  The patient was brought to the electrophysiology laboratory where she was prepped and draped in the usual sterile fashion.  Left upper extremity venography confirmed a patent left subclavian system.


Lidocaine 2% was used to anesthetize the left pectoral region.  Using a scalpel, a 4 cm incision was made over the left deltopectoral groove, avoiding the prior extensive scars.  Using blunt dissection and brief bursts of electrocautery, the device pocket was opened and the device and leads were freed from their adhesions.


Using the appropriate torque wrench, the pulse generator was removed from the leads and removed from the field.  The right atrial lead was inspected and found to have frank insulation failure down to exposed conductor elements.  Although it had appropriate pacing thresholds, it was noted to have highly variable sensing, consistent with the history of noise.  The right ventricular lead was also noted to have some thinning of the insulation, likely due to lead on lead rubbing in the pocket.  It had stable sensing, threshold, and impedance values.


Left subclavian venous access was then obtained with an introducer needle using the venogram as a guide, and a wire was placed under fluoroscopic guidance.  A 7-French sheath was advanced over the wire.  The new RA lead was delivered to the lateral right atrium under fluoroscopic guidance.  The active fixation mechanism was deployed.  Appropriate sensing, threshold, and impedance values were obtained.  The sheath was split and removed.  The lead was secured to the underlying tissue with 0 silk x2.


The existing right atrial lead was capped and the cap secured with 0 silk x2.


The ICD lead was repaired at the site of insulation thinning.  A cap was cut to leave a cylinder of insulation material.  This was placed around the thinned area and secured with 0 silk x2.


The pocket was irrigated with copious Bacitracin and saline solution.  The new pulse generator was connected to the leads with the appropriate torque wrench.  The device and lead assembly were then placed in the cleaned pocket.  The capped RA lead was buried in the pocket under the pulse generator.


Hemostasis was ensured in the pocket with further electrocautery.  There was extensive oozing, which required a great deal of cautery.


The pocket was closed in 3 layers with 2-0, 3-0, and 4-0 absorbable suture material.  Steri-Strips and a Tegaderm dressing as well as a pressure dressing were applied.


The patient tolerated the procedure well.  An Amiodarone bolus and drip were started in the lab, given her VT/VF event, and she was transferred to a monitored bed in stable condition.


IMPLANTED HARDWARE:  The pulse generator is a Medtronic D314DRG, serial number PSK230533H.  RA lead is a Medtronic 5076, serial number PJN3202913.  The RV lead is a Medtronic 6945, serial number TDA116202V from 7/17/01.


The pulse generator that was removed is a Medtronic D154AWG, serial number PUL417896H.  The capped lead is a Medtronic 5568, serial number LVN028871V.


LEAD PARAMETERS:  Through the device, the RA lead senses 3.3 millivolts, threshold 0.75 volts at 0.4 milliseconds, impedance 513 ohms.  RV lead senses 4.9 millivolts, threshold 2.75 volts at 0.4 milliseconds, impedance 323 ohms.  The threshold was consistent with priors through the prior device.  The shock impedances were 50 and 64 ohms.


DFT testing was deferred given the stable RV lead parameters.


The device was programmed AAI-DDD 55-130.  There is a VF zone at 188 with max shocks and a VT monitor zone at 150.


The patient tolerated the procedure well.

What the provider originally had coded was:
33249 (new ICD generator and new lead)
33241 (removal of old generator)
33218 (repair of lead presently in place-wasn't removed)

I had agreed with this coding and put the charges through. When the charges were entered it then fell into our charge review WQ bumping into some CCI edits.  When you look at 33218 there is a NCCI edit with the 33241 and the 33218/33241 combo had an indictaor of "0". When I reviewed the NCCI manual I came across the following:

"23. CPT codes 33218 and 33220 describe repair of single and two transvenous electrodes respectively for a permanent pacemaker or pacing cardioverter-defibrillator. These procedures include incising the skin pocket for the device, removing the device, repairing the lead, and reinserting the original device. CPT codes for device removal, insertion, or replacement or skin pocket revision should not be reported for the typical procedure when the original device is replaced. However, if a new device is used to replace the original device, CPT codes 33227-33229 or 33262-33264 may be reported additionally for replacement with a new device."

Since there was a new device placed I had changed the coding to:

33263.59 (removal of old generator/insertion of new)
33216.59 (insertion of new ICD lead)
33218 I had kept.

33218 came back denied as not paid separately. First off, which scenario was correct for me to code. Was I right in correcting or were things correct the first time? Just wondering how to deal with this denial...

Jessica CPC, CCC


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## Jess1125 (Feb 10, 2014)

*Coded right or not*

Anybody? 

Jessica CPC, CCC


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## jewlz0879 (Feb 11, 2014)

I think the first code selection was correct. I'm wondering, however, since the RA lead was actually replaced with a new one, why bill for the 33218? I do see that physician states there was a repair as well but then it was capped and there is mention of a new RA lead. 

"The new RA lead was delivered to the lateral right atrium under fluoroscopic guidance. The active fixation mechanism was deployed. Appropriate sensing, threshold, and impedance values were obtained. The sheath was split and removed. The lead was secured to the underlying tissue with 0 silk x2."

"The existing right atrial lead was capped and the cap secured with 0 silk x2. The ICD lead was repaired at the site of insulation thinning. A cap was cut to leave a cylinder of insulation material. This was placed around the thinned area and secured with 0 silk x2."

I think I would just bill 33249 and 33241 since there was a new lead and because of that, we can bill for the new device. I think the insurance company is probably thinking, "why bill for a lead repair when there is also CPT captured for a new lead/or new device." 

My two cents.


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## Margaret Morgan (Feb 17, 2014)

Jessica,

This was a very interesting case to read.  My two cents is I would code this as 33249, 33218.  I most likely would not bill the 33241 as it is global to 33218.  I would most likely add a modifier (based on CCI edits) the 33249 to show it was seperate from 33218.

Margaret


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