# dual pacer upgrade to BiV ICD help!!



## kdoughty

I'm struggling with this one.  Can anyone help??

DESCRIPTION OF PROCEDURE: He was prepped and draped in standard fashion,
exposing the left chest.  The old incision was infiltrated with 1% lidocaine.
A 6-cm incision was created through the old incision and carried down until we
engaged the pacemaker pocket.  Using sharp dissection, blunt dissection and
electrocautery, we were able to with gentle extraction remove the previously
implanted pacemaker from the pocket and the set screws.  The old device was a
Medtronic Adapta, serial *[REDACTED]*, implanted 04/06/2012, and the device was
explanted and discarded.  We turned our attention to the right ventricular
lead, which was a Medtronic 5076, 52 cm, serial number *[REDACTED]*, which was
implanted on 04/06/2012.  We put a firm stylet down and retracted the set
screw.  We retracted the fixation mechanism back into the lead.  We dissected
through the fibrous tissue and got through the anchoring sutures.  With gentle
traction and rotation, we were able to extract the old lead, which was
performed easily without any complications.  The patient tolerated the
procedure satisfactorily, and there were no hemodynamic ______ related to the
extraction.  We turned our attention to the venous access and obtained two
axillary vein sticks using modified Seldinger technique, we worked advanced
guide wires into the SVC using a two 9-French sheaths, along was irregular Cook
sheath.  The other was a 9-French safe sheath.  We implanted the right
ventricular lead first.  It was a Boston Scientific Reliance SG, active fix,
single coil, model number 0292, serial *[REDACTED]*, length of lead of 59 cm.  Under
direct fluoroscopy, we were able to manipulate the lead until we found a
satisfactory location in the right ventricular apex with optimal sensing and
physical characteristics.  At this location in the RV apex, the lead had a
sensed amplitude in excess of 30 mV.  We activated the active fixation
mechanism at this location.  The sensed amplitude was, again, between 25 and 30
mV.  Pacing capture threshold was 0.6 V at 0.5 msec with a pacing impedance of
872 ohms.  The lead was sutured to the prepectoral fascia with 0 silk.  We
turned our attention to the left ventricular lead.  Using a Medtronic guiding
sheath and a Polaris quadripolar catheter, we were able to engage the coronary
sinus os and advance the sheath into the coronary sinus.  Contrast venography
was performed, which showed the main CS and a fairly proximal lateral branch,
which appeared to be a satisfactory target for the LV lead.  We were able to,
using a Whisper guidewire, place the LV lead with an over-the-wire technique.
The lead was a Guidant Acuity steerable LV lead, length 80 cm, model #4554,
serial *[REDACTED]*.  This lead was manipulated under direct fluoroscopy to find a
physically stable and electrically optimal location in the distal portion of
this lateral branch.  At this location, in the standard bipolar configuration,
we had a pacing capture threshold of 1 V at 0.5 msec.  There was no
diaphragmatic capture at high pacing outputs.  The impedance was 1232 ohms.
All leads were tested and had passed a similar satisfactory characteristics.
The right atrial lead, which was previously implanted 04/06/2012, was left
alone.  It had a sensed amplitude of 1.8 mV with a pacing capture threshold of
1 V at 0.5 msec with an impedance of 386 ohms.  All leads were anchored to the
prepectoral fascia with 0 silk.  The pocket was widened using electrocautery,
and this was widened both laterally and caudally to accommodate the new device.
The pocket was then copiously irrigated with antibiotic solution.  The device
was a Boston Scientific Energen CRT-D, model number N140, serial *[REDACTED]*, which
was attached to the leads and set screws deployed.  The device was placed in
the pocket.  No anchor suture was placed on the device, and the incision was
closed in layers starting with 2-0 Vicryl for the deep layer and 4-0 Vicryl for
the skin.  Fluoroscopy confirmed satisfactory positioning of all three leads,
the atrial, the right ventricular and the LV lead with adequate amounts of
slack and a wide dispersion between the right ventricle and the left
ventricular lead.  Defibrillation threshold testing was not performed, as the
patient will be loaded with amiodarone and will have DFTs performed after a
satisfactory interval to ensure adequate thresholds.  The device was programmed
to DDDR 60-130 with a VT zone of 160 beats per minute and VF zone of 220 beats
per minute.  Device was programmed to DDDR 60-130.  AV delay was 180/80.

SUMMARY:
1.  Satisfactory extraction of a previously implanted pacemaker and right
    ventricular pacing lead.
2.  Upgrade to biventricular implantable cardiac defibrillator.


----------



## jtuominen

Because you are upgrading from a Pacemaker system to an BIV ICD system, the new "package" type codes don't apply to your situation. You have to code the removal of the pacemaker components seperately from the insertion of the ICD components.
Here is how I would code this:

33233 - Removal of your dual pacemaker pulse generator
33235 - Extraction of the RV Lead from a patient that had a dual chamber system in place

33249 - Insertion of the new RV lead and Insertion of the CRT-D (BIV) generator (you left your old RA lead in place and just connected it to this new generator)
33225 - Insertion of an LV lead at the time of a new pulse generator insertion

Your pocket revision/upsizing is included in your insertion of your new device. So you can't charge for that seperately in your situation. DFTs were not performed so 93641 is not appropriate.

Also check with your physician as to what the clinical indication was for the upgrade to BIV ICD.
Your patient may qualify for ICD/BIV ICD insertion for primary prevention status.
Based on the dates listed in your report, sounds like the patient probably has had a relatively acute onset of some new heart failure type symptoms or perhaps an epiosode of VT/VFIB after their pacer insertion?? April to now is not that long for such a significant upgrade without something going on.
If your patient is a Primary Prevention Medicare/Medicare Replacement Product Insured Outpatient, you will need to add the Q0 modifier to indicate the primary prevention status.
My guess though is that since your patient had an extraction in this case that they will be inpatient status. 
But you never know these days it seems!

Hope that helps!
Jayna


----------



## twizzle

I presume you have a diagnosis to work with.
33249,33225,33234,33233 should work.
If the patient is Medicare you may need Q0 on the 33249 depending on the reason for the upgrade. It looks like the patient may have a-fib if they are using Amiodarone in which case you would not need the Q0.
Hope this helps


----------



## jtuominen

Wassock, don't you think 33235 is a better choice over 33234, as this was a dual chamber pacemaker system in place? Codes 33234 and 33235 are based on the type of system, not on the number of leads removed.


----------



## kdoughty

Diagosis':
1.  Cardiac arrest.
2.  Inducible sustained, monomorphic VT.
3.  NYHA class 3 heart failure.
4.  Acute-on-chronic systolic heart failure.
5.  Left bundle branch block with QRS duration of greater than 120 msec.


----------



## jtuominen

With that VT/CA diagnosis, your patient qualifies for secondary status, so the primary prevention/Q0 modfiier will not apply in this situation.


----------



## kdoughty

Thanks a ton.  I didn't think I would need the Q0 because of the 1st two diagnosis but my brain isn't working today at all...lol.  Thanks again for all your help!!


----------



## jtuominen

I have had those days too, when you read the report 12 times and its like reading a foreign language? oh yeah those happen. Good luck!


----------



## twizzle

jtuominen said:


> Wassock, don't you think 33235 is a better choice over 33234, as this was a dual chamber pacemaker system in place? Codes 33234 and 33235 are based on the type of system, not on the number of leads removed.[/QUOTE
> We always have this dispute at work. To my mind, and from advice from other sources, we bill it as the number of leads removed rather than the device that is in-situ. After all, the work involved in removing a lead from a single or dual system is the same, whereas the work in removing 2 leads is more involved. Perhaps Jim Collins can offer his services here.
> Andy


----------



## jtuominen

Yes, I have had that dispute in the past too.

But I think what has clicked for me is that the word before the semicolon in code 33234 is electrode(s). That "(s)" made me realize that 33235 really reads: "Removal of transvenous pacemaker electrode(s): dual lead system"--which in my mind means "removal of 1 or 2 leads from a dual chambered system".

In the poster's situation she had a patient with 2 leads in place at the start of the procedure, with the RV extracted and the RA reused, so with the above thinking my mind led me to 33235 over 33234.

Additionally, the way I see it there was more procedural complexity and higher medical decision making that had to be provided by the physician in order to safely perform the extraction on this patient that has a condition that necessitates two chamber (and by the end of it all three chamber) cardiac rythmn management. Which I think then really translates well to assigning the higher RVU CPT of the two, which would be 33235.

Don't you just love this stuff?


----------



## twizzle

Contentious issue which would be better served by having better CPT code descriptors. I would still like input from Jim Collins. I take your point about the electrode(s) though. I used to bill it the way you're suggesting but I guess the myriad of information pointed me and my colleague to bill it the way I suggested, right or wrong. Unfortunately it's always difficult to get a 100% true answer.


----------

