# ICD generator removal, lead repair, and new pacemaker generator insertion issue



## shannonjmoss (Apr 12, 2017)

Hi everyone,
I am hoping to get some feedback on this case I am stumped on.  

Some details from the case: 



"The device was dissected free and delivered from pocket.  The extrathoracic portion of each lead was carefully dissected free and found to be inspected. 

The RV lead was discovered to have an insulin break in its outer insulation only, which did not affect the electrical elements of the lead.  All other leads were intact.  Leads removed from the generator and tested electrically.  They were found to have adequate function.  Of note,  the LV lead in the old device had been programmed to pace in the vector from the LV tip to the RV coil.  Since this vector was not available in the pacemaker, the lead was tested in the unipolar configuration LV tip to pocket.  This resulted in excellent thresholds with no diaphgragmatic capture at high output.  

The new device was taken on the table.  Each lead was inserted into the correct socket on the header and the set screws were tightened.  The high voltage portions of the RV lead were capped and sutured.  The insulation break in the RV lead was repaired using surgical adhesive.  The lead was then wrapped under the can and the pacing pacemaker was placed in the pocket with the excess lead under it. 

The generator was anchored to the base of the pocket, and closed.  

So to sum it up the patient had an ICD generator removed, existing atrial lead, ventricular lead (RV) which was repaired with surgical adhesive, left ventricular lead, and a newly placed pacemaker generator.  

We initially charged: 
33218- Repair of electrode for permanent pacemaker or defibrillator device
33241- Removal of defibrillator pulse generator
33221- Insertion of pacemaker pulse generator with existing multiple leads

We received a CCI edit indicating that both 33241 and 33221 were components of 33218 and "Modifier not permitted with code pair"

After doing a bit of research I found information that indicated the repair of the lead includes the removal of the generator and insertion of SAME generator.  

So we have removed our ICD removal charge of 33241.   

I am absolutely stumped though for how to charge the pacemaker generator insertion as it will not allow the code with a modifier.  

The only codes I found that were allowed to be charged as well were 33227-33229 (Removal and replacement of Pacemaker generator) or 33262-33264 (Removal and replacement of ICD generator)  But we cannot charge these as we removed an ICD and inserted a Pacemaker.  

Can anyone advise???

Thank you.


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## senpai_j (Apr 12, 2017)

"The new device was taken on the table. ... The insulation break in the RV lead was repaired using surgical adhesive."

When I read the coder's desk reference, this CPT code seemed to be for describing removing the PPM or ICD just to repair the lead (thus reinserting the same device). The CDR didn't even describe removing the lead from the body and I think 33218 is for when the purpose of the procedure is to repair the lead. 

CPT Assistant from 1996 says, "Use one of these codes to report a repair of a pacing electrode or electrodes. This includes services like splicing a fracture and/or modifying a terminal pin, repair of an insulation defect. This repair procedure is not to be coded when replacement of the entire pacemaker system including electrodes (eg, 33206, 33207) is reported. Removal and its subsequent reinsertion into the same skin pocket, of the pulse generator to gain access to the lead and electrode is included in the repair procedure." This supports my previous thought about the use of 33218.

The primary procedure is removal of the ICD and inserting the PPM. What the physician describes seems incidental to the replacement of the device. I'd keep 33241 and 33221 and take off the 33218.


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