# Lead Replacement



## crhunt78 (Apr 5, 2013)

Hello!  I used to dabble in Cardiology coding but am not up to par and really need some help with all of these new CPT codes.  I am trying to code a pacemaker lead replacement but am not sure which way to go.  Here is a copy of the op note:

Following oral and written informed consent, the patient was brought to the OR in a fasted, unsedated state.  The presenting heart rhythm was atrial flutter (tcl 300 msec) with variable AV block.  The patient was prepared and draped in the usual sterile fashion. The patient received cefazolin 2gram IVPB prior to incising.  The patient received general anesthesia via LMA for sedation.  Additionally, 2% lidocaine was infiltrated subcutaneously over the left infraclavicular region coincidental to the prior scar.  Fluoroscopy was used to indentify anatomical landmarks and the location of the pacemaker pulse generator and pacemaker leads.


"An incision was made using a #10 scalpel coincidental to the prior incision.  Blunt dissection and electrocautery were used to enter the pacemaker pocket.  The silk suture securing the pulse generator to the floor of the pocket was identified, cut, and removed.  The pacemaker pulse generator was removed from the pocket.  The leads were disconnected from the pacemaker header and attached to the PSA.  The right ventricular lead was found to have a high capture threshold (>8V at 1.5ms) and poor sensing.  The right atrial lead had normal sensing and pacing impedance.  The atrial flutter tachycardia cycle length was 300 msec.  The right atrium was paced at 270 msec and the rhythm converted to sinus.  The pacing threshold was then measured (see below).


The silk suture on the RV suture sleeve was cut and removed.  A stiff (purple) stylet was inserted into the RV lead.  The RV lead was freed by using gentle traction.  The RV lead was withdrawn from the patient's body and set aside (It will be sent to Medtronic, Inc for analysis).  A venogram was performed using 15cc of iodinated contrast dye x2 injections to demonstrate the location and patency of the left axillary/subclavian vein.  Vascular access was obtained with a micropuncture kit using the modified Seldinger technique under fluoroscopic guidance x1.  The micropuncture wire was upsized to a 0.35 J wire and a 7Fr sheath was inserted into the left axillary vein and flushed.  A new active fix pacemaker lead was placed under fluoroscopic guidance and secured distally in the RV apical septum and proximally to the underlying fascia using O-Ethibond x2.  High output pacing confirmed the absence of diaphragmatic capture.  The right atrium was paced at 300msec through the PSA and the patient reverted to atrial flutter with variable AV block (presenting heart rhythm).  


The pocket was then copiously irrigated with a saline-bacitracin solution.  FloSeal was injected into the pocket.  There was excellent hemostasis.  The pacemaker pulse generator was then re-introduced to the surgical field and connected to the leads.  Care was taken to ensure that the leads were securely fastened in the correct positions within the device header.  The pulse generator was then inserted into the pocket and secured to the fascia with O-Ethibond x1.  The pocket was then closed in three layers of absorbable Vicryl suture.  Steri-strips and a sterile occlusive dressing were placed over the incision site.


Thanks for your help in advance!!


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## ilovemyboys777@yahoo.com (Apr 5, 2013)

Cardiology coding is difficult at times especially with Pacemakers and ICD / bi-ventricular pacemakers / ICD.  All my code sheets are at work but first thing Monday morning I can send you the codes I would use.  Also if you would like me to fax you cheat sheets for PPM / ICD I will be more than happy to.  Sorry you have to wait till Monday for my response! Have a great weekend!


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## crhunt78 (Apr 5, 2013)

That would be fantastic!  I will send you my fax and email in a private message.  I really do appreciate your help!


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## twizzle (Apr 6, 2013)

HILLIC said:


> Hello!  I used to dabble in Cardiology coding but am not up to par and really need some help with all of these new CPT codes.  I am trying to code a pacemaker lead replacement but am not sure which way to go.  Here is a copy of the op note:
> 
> Following oral and written informed consent, the patient was brought to the OR in a fasted, unsedated state.  The presenting heart rhythm was atrial flutter (tcl 300 msec) with variable AV block.  The patient was prepared and draped in the usual sterile fashion. The patient received cefazolin 2gram IVPB prior to incising.  The patient received general anesthesia via LMA for sedation.  Additionally, 2% lidocaine was infiltrated subcutaneously over the left infraclavicular region coincidental to the prior scar.  Fluoroscopy was used to indentify anatomical landmarks and the location of the pacemaker pulse generator and pacemaker leads.
> 
> ...


You would code 33235 for removal of the lead. This can be confused with 33234 but the directions encourage you to use 33235 for removal of electrode(s) from a dual lead system even if only one lead is removed. For insertion of a new lead use 33216. The venogram done prior to the new lead placement cannot be billed as it is considered roadmapping. However, if they had said that the venogram revealed an anatomical anomaly such as severe stricture or stenosis of the vein that may cause a problem with lead placement, then you could bill the venogram.
Hope this helps. (I have done this from memory as my books are at work so I apologize if there are any errors).


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## crhunt78 (Apr 10, 2013)

wassock said:


> You would code 33235 for removal of the lead. This can be confused with 33234 but the directions encourage you to use 33235 for removal of electrode(s) from a dual lead system even if only one lead is removed. For insertion of a new lead use 33216. The venogram done prior to the new lead placement cannot be billed as it is considered roadmapping. However, if they had said that the venogram revealed an anatomical anomaly such as severe stricture or stenosis of the vein that may cause a problem with lead placement, then you could bill the venogram.
> Hope this helps. (I have done this from memory as my books are at work so I apologize if there are any errors).



Thank you SO much for your reply!  I looked at the codes and I agree with using 33235 and 33216.  Where did you find the instructions to use the dual lead system even if one lead is replaced?  I can see how that would be very confusing....Thanks again!


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## twizzle (Apr 15, 2013)

*33234 and 33235*

It's like a lot of these situations. Code descriptors are assembled but are open to interpretation. i did some research on the internet using Boston Scientific and other pacer manufacturer websites and came to the conclusion that this was the way to bill these. Just the CPT description by using the word electrode(s) has changed the way I bill these. I always used 33234 for one lead and 33235 for more than one. I did have a situation last week where my doc had done a generator change, removing a dual chamber pacer and inserting a single chamber, with removal of one lead. In this situation I used 33234 for lead removal as the final device in-situ was a single chamber device. Not sure if this was correct or not.
It's all confusing because those that write these code descriptions are unable to put together clear and conclusive advice.
You are always welcome to send me a private message if you need any more pacer/icd/electrophysiology advice.


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## jewlz0879 (Apr 16, 2013)

I agree with wassock and also Dr. Z and Jim Collins suggest you code that way as well; you should code based on the system the patient has with respect to existing PM/ICD systems. 

HTH


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