# Loop recorder removal/pacer insert



## lcouto

Hi. Patient had a loop recorder implanted in March.. 3 weeks later my doctor removed the loop recorder and inserted a Dual Chamber Pacemaker.. When we billed this we billed a 33284 for the removal of the loop recorder and a 33208 for the pacer insert. Medicare is denying stating  Payment is included in allowance for other procedure. Was this billed correctly or should there be a modifier used? Please help !!!  I attached the report 

Pre-procedure Diagnoses 
  1. Tachy-brady syndrome  
  2. Paroxysmal atrial fibrillation

  Post-procedure Diagnoses 
  1. Tachycardia-bradycardia
  2. Paroxysmal a-fib   
  BRIEF OPERATIVE NOTE


Date of Surgery:
4/12/2013


Pre-operative Diagnosis:  
Tachycardia- Bradycardia Syndrome
Paroxysmal Atrial fibrillation


Post-operative Diagnosis:  
Same as above


Procedure Performed :
Implantation of Permanent Pacemaker
Removal of  Reveal XT loop Recorder

Specimens Removed:   
Medtronic Reveal XT RAB 483394H


Implants and Procedure Description:  
After informed consent was obtained, the patient was transported in a nonsedated condition to the cardiac catheterization suite. The patient was given moderate conscious sedation. The patient was prepped and draped in a sterile fashion and a "timeout" was taken.  


ACCESS and POCKET FORMATION:
Lidocaine was used to infiltrate the skin and subcutaneous tissue overlying the left pectoralis muscle. The patient was placed in Trendelenburg position. Percutaneous access was obtained in the subclavian vein utilizing the modified Seldinger technique. An .035 wire was advanced into the right atrium under fluoroscopic guidance. Sharp incision was made in the skin. Utilizing a combination of sharp and blunt dissection, a pocket was formed in the prepectoral fascia.  I was able to dissect along the prepectoral fascia and removed the Reveal XT loop recorder through the incision for the pacemaker pocket.

VENTRICULAR LEAD:
Over the .035 wire, an 8 French peel-away sheath was advanced. The dilator was removed, and a second .035 wire wa
s placed through the sheath. The sheath was removed and then reintroduced over one of the .035 wires. The wire and dilator were exchanged then for the ventricular pacing lead. The lead was an passive fixation lead (Medtronic 4092-58 with serial number LEP521453V) Utilizing curved and straight stylettes, the lead was positioned and secured in the right ventricular apex. It was tested and found to have R waves of 11.3 mV, impedance 564 ohms, threshold was 0.6 volts, current 1.3 milliamps. Adequate slack was placed in the lead under fluoroscopic guidance. The lead was tested with output of 10 V and did not stimulate the diaphragm.


ATRIAL LEAD:  
Attention was then turned to the atrial lead. Over the second .035 wire a second dilator and sheath were placed. The wire and dilator were exchanged then for the atrial pacing lead. The lead was an active fixation lead (Medtronic 5076-52 with serial number PJN3002013.) Utilizing curved and straight stylettes, the lead was positioned and secured in the right atrial appendage. It was tested and found to have P waves of 3.8 mV, impedance 866 ohms, threshold was 1.0 volts, current 1.6 milliamps. Adequate slack was placed in the lead under fluoroscopic guidance. The lead was tested with an output of 10 V and did not stimulate the diaphragm. 


CLOSURE:
The leads were then secured to the pectoralis muscle with non-resorbable suture. I then attached the pulse generator (Medtronic ADAPTA ADDR01 with serial number NWB233430H) The leads and pulse generator were incorporated in the pocket. The pocket was copiously irrigated. The subcutaneous fascia was closed with interrupted Vicryl suture. The skin layer was closed with a subcuticular Vicryl stitch. Final fluoroscopy demonstrated adequate slack in the leads. The wound was dressed in a sterile fashion.


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## TWinsor

looks correct to me.  There is not a CCI edit.  I would appeal with notes.

HTH


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## theresa.dix@tennova.com

lcouto said:


> Hi. Patient had a loop recorder implanted in March.. 3 weeks later my doctor removed the loop recorder and inserted a Dual Chamber Pacemaker.. When we billed this we billed a 33284 for the removal of the loop recorder and a 33208 for the pacer insert. Medicare is denying stating  Payment is included in allowance for other procedure. Was this billed correctly or should there be a modifier used? Please help !!!  I attached the report
> 
> Pre-procedure Diagnoses
> 1. Tachy-brady syndrome
> 2. Paroxysmal atrial fibrillation
> 
> Post-procedure Diagnoses
> 1. Tachycardia-bradycardia
> 2. Paroxysmal a-fib
> BRIEF OPERATIVE NOTE
> 
> 
> Date of Surgery:
> 4/12/2013
> 
> 
> Pre-operative Diagnosis:
> Tachycardia- Bradycardia Syndrome
> Paroxysmal Atrial fibrillation
> 
> 
> Post-operative Diagnosis:
> Same as above
> 
> 
> Procedure Performed :
> Implantation of Permanent Pacemaker
> Removal of  Reveal XT loop Recorder
> 
> Specimens Removed:
> Medtronic Reveal XT RAB 483394H
> 
> 
> Implants and Procedure Description:
> After informed consent was obtained, the patient was transported in a nonsedated condition to the cardiac catheterization suite. The patient was given moderate conscious sedation. The patient was prepped and draped in a sterile fashion and a "timeout" was taken.
> 
> 
> ACCESS and POCKET FORMATION:
> Lidocaine was used to infiltrate the skin and subcutaneous tissue overlying the left pectoralis muscle. The patient was placed in Trendelenburg position. Percutaneous access was obtained in the subclavian vein utilizing the modified Seldinger technique. An .035 wire was advanced into the right atrium under fluoroscopic guidance. Sharp incision was made in the skin. Utilizing a combination of sharp and blunt dissection, a pocket was formed in the prepectoral fascia.  I was able to dissect along the prepectoral fascia and removed the Reveal XT loop recorder through the incision for the pacemaker pocket.
> 
> VENTRICULAR LEAD:
> Over the .035 wire, an 8 French peel-away sheath was advanced. The dilator was removed, and a second .035 wire wa
> s placed through the sheath. The sheath was removed and then reintroduced over one of the .035 wires. The wire and dilator were exchanged then for the ventricular pacing lead. The lead was an passive fixation lead (Medtronic 4092-58 with serial number LEP521453V) Utilizing curved and straight stylettes, the lead was positioned and secured in the right ventricular apex. It was tested and found to have R waves of 11.3 mV, impedance 564 ohms, threshold was 0.6 volts, current 1.3 milliamps. Adequate slack was placed in the lead under fluoroscopic guidance. The lead was tested with output of 10 V and did not stimulate the diaphragm.
> 
> 
> ATRIAL LEAD:
> Attention was then turned to the atrial lead. Over the second .035 wire a second dilator and sheath were placed. The wire and dilator were exchanged then for the atrial pacing lead. The lead was an active fixation lead (Medtronic 5076-52 with serial number PJN3002013.) Utilizing curved and straight stylettes, the lead was positioned and secured in the right atrial appendage. It was tested and found to have P waves of 3.8 mV, impedance 866 ohms, threshold was 1.0 volts, current 1.6 milliamps. Adequate slack was placed in the lead under fluoroscopic guidance. The lead was tested with an output of 10 V and did not stimulate the diaphragm.
> 
> 
> CLOSURE:
> The leads were then secured to the pectoralis muscle with non-resorbable suture. I then attached the pulse generator (Medtronic ADAPTA ADDR01 with serial number NWB233430H) The leads and pulse generator were incorporated in the pocket. The pocket was copiously irrigated. The subcutaneous fascia was closed with interrupted Vicryl suture. The skin layer was closed with a subcuticular Vicryl stitch. Final fluoroscopy demonstrated adequate slack in the leads. The wound was dressed in a sterile fashion.




Both 33282 and 33284 have 90 day global period. So you will need to add a modifier. Now which one ?


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## bethh05

I know this is a little late but I found a retired LCD on the CMS website that states 33284 is not separately reportable when performed on the same day as pacemaker insertion. 
http://www.findacode.com/medicare/p...-medicare-info.php?type=ARTICLE&type_id=41268


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## j.monday7814

bethh05 said:


> I know this is a little late but I found a retired LCD on the CMS website that states 33284 is not separately reportable when performed on the same day as pacemaker insertion.
> http://www.findacode.com/medicare/p...-medicare-info.php?type=ARTICLE&type_id=41268



wow, I'm kinda surprised it is automatically included but there aren't any NCCI edits against billing the two codes together. We always bill the ILR removal during pacemaker insertion. Maybe this is a MAC specific policy which doesn't apply to us?? we've never had an issue getting paid on both codes.


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## bethh05

This is a follow up from my previous post, I queried the NCCI contractor for CMS about the use of 33208 and 33284 and this is the response I received:
Thank you for your inquiry dated March 10, 2015 to the Centers for Medicare & Medicaid Services (CMS).  CMS owns the National Correct Coding Initiative (NCCI) program and determines its contents.
On behalf of CMS, I am providing a response at its request.  

The absence of an NCCI edit does not mean that one code may be reported with another code.  Please refer to the language in the Introduction, page 6 of the National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services: 

"The National Correct Coding Initiative Policy Manual for Medicare Services and the edits were developed for the purpose of encouraging consistent and correct coding and reducing inappropriate payment.  The edits and policies do not include all possible combinations of correct coding edits or types of unbundling that exist.  Providers are obligated to code correctly even if edits do not exist to prevent use of an inappropriate code combination.  If a provider determines that he/she has been coding incorrectly, the provider should contact his/her Carrier, Fiscal Intermediary, or MAC about potential payment adjustments."

Since you mention a local coverage determination (LCD), please contact your local Medicare claims processing contractor to verify whether this information is included in another related LCD or payment policy that is active, or whether the LCD is in fact retired and no longer valid.  From the NCCI edit perspective, there is nothing in NCCI to prevent a provider from reporting both of these codes for the same beneficiary, on the same date of service, rendered by the same performing provider.


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## Jess1125

Just out of curiosity, when was the loop recorder inserted? If it was in the 90 days prior you would need to put modifiers on the 33284 and 33208 such as a -78 on the 33284 and -79 on the 33208. I can say I've had this scenario once or twice but don't recall there being any issues with payment. 

Jessica CPC, CCC


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## j.monday7814

we all know that NCCI edits cannot capture all possible coding scenarios but ILR explant with a pacemaker insertion is extremely common and I'm sure if Medicare believed it was being unbundled inappropriately then there would be an edit for it. seems absolutely ridiculous that an ILR explant would be included in the pacemaker implant.


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## msorrell1

*Loop Record Removal same day PPM insertion*

Per the original question in 2013, did anyone determine why the claims are being denied?  There were several issued discussed in the threads.  Mine are being denied if within the 90 global period of the implant of the ILR, the doctor removes the ILR and replaces it with a PPM.  I am using 33284 for removal and 33208 for insertion of PPM.  I'm going in circles and I hope someone may be able to help me  mel.sorrell@yahoo.com


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## twizzle

msorrell1 said:


> Per the original question in 2013, did anyone determine why the claims are being denied?  There were several issued discussed in the threads.  Mine are being denied if within the 90 global period of the implant of the ILR, the doctor removes the ILR and replaces it with a PPM.  I am using 33284 for removal and 33208 for insertion of PPM.  I'm going in circles and I hope someone may be able to help me  mel.sorrell@yahoo.com


Well, if in the global period as per the original example and your example, the pacer 33208 obviously needs a modifier as 33282 has a 90-day global so 33208 needs a 79 modifier (there will be different diagnoses for the 33282...probably syncope, and the pacer....SSS or bradycardia) so unrelated, and the ILR removal is related to the ILR placement so will need modifier 78. 33208-79, 33284-78


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