# Biventricular Pacemaker



## Jim Pawloski (Jan 13, 2015)

How should this be billed.  I want to bill 33214, the techs want to bill 33225 and 33229.  Who is right and why?

Thanks,
Jim Pawloski, CIRCC


Procedure
Procedure Type
Pacemaker:Miscellaneous, VENOGRAM UNILATERAL (75820), PPM UPGRADE (+LV),
REMOVAL/RPL PPM GEN MLTPL/BIV (33229), LV LEAD INSRT AT TIME OF IMPLANT
(33225)
Clinical Presentation
This patient is a 77-year-old woman with morbid obesity and chronic atrial
fibrillation as well as diabetes who had an AV junctional ablation several
decades ago and has good pacer dependent since.
She had an anterior myocardial infarction in the past and had moderate LV
dysfunction.
Over the past year she's had significant worsening of LV function with
ejection fraction now of 33% and class III congestive heart failure. She
remained symptomatic despite optimal medical therapy.
Recent cardiac catheterization showed a mid LAD stenosis with a negative
fractional flow reserve and no other significant coronary stenosis.
A long discussion was had with the patient and a decision was made to
upgrade her to a biventricular pacer to improve her symptoms, congestive
heart failure, and LV function. She does not wish to have an ICD. I think
this is a reasonable decision given her age and comorbidities.
Conclusions
Implantable Device Summary
Summary
The patient was prepped and draped in a standard sterile fashion and 2 g of
Kefzol was given IV.
Venogram was performed showing a patent left subclavian vein.
An incision was made over the old incision subclavian vein was entered
without difficulty. Prior levo phase coronary angiogram revealed the
position of the coronary sinus and this was cannulated without difficulty.
The venous anatomy was quite difficult. A posterolateral vein was very
tortuous and could not be used.
A mid lateral vein connected to the posterior descending vein was found and
this was cannulated and the lead placed. This was quite difficult despite
having a wire down to the lateral vein out the PDA and out the coronary
sinus. Multiple LV leads would not follow the wire. A buddy wire was needed.
A good lead position was finally obtained with good sensing and pacing
thresholds and a narrow biventricular QRS was seen.
The new LV lead was tied down using 0 silk by Silastic sleeves.
The lead was securely fastened then attached to the new unit. The old device
was removed and the RV apical lead was removed and attached to the new
device.
The device and leads were placed in the pocket and the wound was irrigated
with copious amounts of bacitracin solution. The device was tied down with 0
silk.
A standard multilayer closure was used. Patient tolerated procedure well.
A standard multilayer closure was used


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## Chlrtrep (Jan 13, 2015)

I would code as a multi-lead change-out (33229) and left ventricular lead add-on (33225).

A dual chamber generator is not the same as a BiV generator. The placement of an RV lead is not as involved as palcementof LV Lead.

I am assuming this was a single chamber(RV) PPM being upgraded to an Multi Chamber PPM with the addition of an LV lead


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## dpeoples (Jan 22, 2015)

Jim Pawloski said:


> How should this be billed.  I want to bill 33214, the techs want to bill 33225 and 33229.  Who is right and why?
> 
> Thanks,
> Jim Pawloski, CIRCC
> ...



Jim,
I have a table in my cpt book (professional edition, pg 187) that specifies this procedure. The codes listed are :33225 +33228 or 33229. I only see 2 leads documented, so I would code 33225+33228. And, I agree, this is more involved than just the requirements of 33214.
Sorry for the delay..

HTH


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## Jim Pawloski (Jan 26, 2015)

dpeoples said:


> Jim,
> I have a table in my cpt book (professional edition, pg 187) that specifies this procedure. The codes listed are :33225 +33228 or 33229. I only see 2 leads documented, so I would code 33225+33228. And, I agree, this is more involved than just the requirements of 33214.
> Sorry for the delay..
> 
> HTH



No problem, I thank you for you input.

Thanks,
Jim Pawloski, CIRCC


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