# Help with Pacemaker/lead replacement



## Chelsea1 (Jun 14, 2016)

I am reviewing some sample notes with codes for a upcoming exam and I do not understand this one. Can someone take a look at it and explain why the answers are what they are and not the code of 33206 alone that I had thought it was. I thought the code included remove and insert. If at all possible, please advise me on where I may be able to find more information on it.   Thanks for looking.

Patient with Dual Chamber pacemaker presents for generator change due to end of life. The left pectoral region was prepped and draped using sterile technique. An approximately 4cm incision was made at the surgical site. This incision was carried down through the subcutaneous tissue to the premuscular fascia using sharp and blunt dissection and electrocautery. The pacemaker pocket capsule was incised, and the old generator was extracted from the pocket and discarded. The leads were dissected away from the fibrous adhesions using careful sharp and blunt dissection. The header screws were unscrewed using a hex wrench, and the leads pulled from the header. Testing of the lead system was then performed. Each lead was tested with a pacing system analyzer. The ventricular lead tested appropriately, but the atrial lead was found to be faulty. It was decided to replace the right atrial lead. The old lead was removed by tugging on it. A long guidewire was advanced into the right atrium. An introducer was placed over the guidewire, and then through the introducer a pacemaker lead was advanced to the right atrial appendage. The introducer was peeled away, and the lead was positioned until appropriate pacing and sensing thresholds were obtained. Each lead was inserted into the new pacemaker header, and the set screws were tightened. The system was then tested. The new dual chamber pacemaker generator was placed into the existing pocket. After checking the pocket for hemostasis and flushing the pocket with copious amounts of antibiotic solution, the pocket was closed in three layers with Vicryl absorbable suture. Steri-strips were applied to the incision, and the wound was dressed with a sterile pressure dressing. 
Codes: 33206, 33233, 33235


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## CodingKing (Jun 14, 2016)

I always look at the chart that provided in the CPT book first. It states for Removal and replacement of pulse generator and transvenous electrodes 33233 + (33234 or 33235) + (33206, 33207, 33208). 

33233 - Removal of pulse generator
33234 - Removal of transvenous electrodes(s)- (This is for the removal of the faulty lead that was documented)
33206 - Insertion or replacement of pulse generator, including the electrodes(s) (This does not include the removal)

Also there is parenthetical note under 33206-33208 matching what is in the chart. It states "For removal and replacement of pacemaker pulse generator and transvenous electrode(s), use 33233 in conjunction with either 33234 or 33235 and 33206-33208."

I highlighted the relevant portions of the note



Chelsea1 said:


> *Patient with Dual Chamber pacemaker presents for generator change due to end of life*. The left pectoral region was prepped and draped using sterile technique. An approximately 4cm incision was made at the surgical site. This incision was carried down through the subcutaneous tissue to the premuscular fascia using sharp and blunt dissection and electrocautery. The pacemaker pocket capsule was incised, and the old generator was extracted from the pocket and discarded. The leads were dissected away from the fibrous adhesions using careful sharp and blunt dissection. The header screws were unscrewed using a hex wrench, and the leads pulled from the header. Testing of the lead system was then performed. Each lead was tested with a pacing system analyzer. The ventricular lead tested appropriately, but *the atrial lead was found to be faulty. It was decided to replace the right atrial lead*. The old lead was removed by tugging on it. A long guidewire was advanced into the right atrium. An introducer was placed over the guidewire, and then through the introducer a pacemaker lead was advanced to the right atrial appendage. The introducer was peeled away, and the lead was positioned until appropriate pacing and sensing thresholds were obtained. Each lead was inserted into the new pacemaker header, and the set screws were tightened. The system was then tested. The new dual chamber pacemaker generator was placed into the existing pocket. After checking the pocket for hemostasis and flushing the pocket with copious amounts of antibiotic solution, the pocket was closed in three layers with Vicryl absorbable suture. Steri-strips were applied to the incision, and the wound was dressed with a sterile pressure dressing.
> Codes: 33206, 33233, 33235


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## Chelsea1 (Jun 14, 2016)

Thank you so much. That really does help out a lot!!!!!


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