# Lead placement/repositioning



## lcaskew1 (Mar 18, 2015)

Can I bill 33215 twice since 2 leads were repositioned? And since it was only a lead repositioning and a lead placement and not a full ICD placement, can I bill separately for the coronary sinus venogram? If so, is this right? 
33224, 33215x2, 36215, 75820-26.

PROCEDURES:  Are as follows:
1.  Right ventricular apical defibrillation lead repositioning.
2.  Right atrial lead repositioning.
3.  Coronary sinus venogram.
4.  Coronary sinus lead placement.

INDICATIONS:  The patient recently underwent an attempt at BiV-ICD placement.  The procedure was complicated by coronary sinus perforation, and the procedure was aborted.  We are now scheduled to again return to an attempt at placing the left coronary sinus lead.

DESCRIPTION OF PROCEDURE:  Informed consent was obtained.  A CRNA was in attendance for general sedation and local anesthesia was used.  The left
infraclavicular incision was opened and the device was removed.  The
ventricular lead was repositioned to a position in the inferior aspect of the
right ventricular apex.  The lead was secured using an anchoring sleeve and 2
subcutaneous sutures.  We then also repositioned the atrial lead into the
right atrial appendage, and the lead was also secured using 2 anchoring
sleeves.  A long sheath was then introduced into the left subclavian vein.
Through this, a quadripolar mapping catheter was advanced, and the coronary
sinus was mapped and entered.  The long sheath was threaded over the mapping catheter, which was then removed and replaced with a 6-French balloon-tipped catheter.  A coronary sinus venogram was obtained, which showed a very large apical branch, and a small high posterolateral branch.  We elected to try for the higher posterolateral branch, and a balloon-tipped catheter was removed
and replaced using a Medtronic 4298-88 lead.  The lead was finally advanced
approximately 4 cm down from the coronary sinus.  Excellent electrograms,
thresholds, and impedances were obtained with good sensing data.  No
diaphragmatic pacing was noted at 10 volts.  All equipment was carefully
removed and the lead was secured using an anchoring sleeve and 2 subcutaneous sutures.  All leads were then reconnected with a previously employed Medtronic biventricular generator.  Tug test on the tie-down site and the generator were all satisfactory.  The generator was placed in the pocket, logo up, with redundant lead segments under the generator.  The incision was closed in 3 layers.  Steri-Strips were applied.  Fluoroscopic visualization showed all 3 leads to still be in good position.  No complications occurred during the procedure.

Any help would be greatly appreciated.


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## j.monday7814 (Mar 18, 2015)

The MUEs on 33215 show it can be billed up to twice during the same session. It may have to be appealed but the documentation easily supports it being billed twice. 36215 and 75820 are not separately billable, all catheter placement and fluoro is included in all of the pacemaker/ICD codes. And since there wasn't a generator change the 33224 is correct.


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## Misty Dawn (Mar 20, 2015)

I agree.  CPT 33224 is correct as this code is used for the LV lead placement attached to an existing device.
33224.58.51
33215.59.58
33215.59.58.51
Coded per CPT/HRS guidelines. Check with payer for 51 modifier use.

Code 33215 is a component of column 1 code 33224 but a modifier is allowed in order to differentiate between the services provided. Since this is for 3 different leads modifier 59 acceptable to differentiate.

If both the RA and RV leads must be re-positioned, code 33215 for the first lead and 33215.51 for the second lead.

Misty Sebert CPC, CCC, CCVTC
The Coding Network, LLC
www.linkedin.com/in/mistysebertcardiologycoder


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## lcaskew1 (Mar 20, 2015)

So Misty, I am to use all of those modifiers? Would you mind helping me understand the use of each of the modifiers in the last 33215? I didn't realize both 59 and 51 could be used in the same code. And is the 58 there because in the indication it said that a recent attempt was made at BiV-ICD placement? This is my first year coding, so I am eager to learn all the reasons modifiers are used so that I will remember it the next time. Thank you so much for your help. And a thank you also goes to Jeremy.


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## Misty Dawn (Mar 20, 2015)

58 is because the provider planned for the pt to return for the related procedure. (Is it still in GP?)  If it was unplanned it would be a 78 and if unrelated it would have been a 79 modifier.  

33215 bundles into your 33224 so 59 modifier is required on both 33215 because these 3 procedures are done on separate leads.  

51 is from the CPT/Heart Rhythm Society coding book.  Example in the HRS coding guide note if both RA and RV leads are re-positioned you code 33215 and 33215.51.  

33224 is a secondary procedure to the related device implant, with this being a planned/related procedure the 51 modifier by CPT/HRS guidelines is appropriate.

Check with your payer on the 51.  Medicare does not need the 51 appended but  some commercial insurances do require it. So take a look at the payers guidelines on the 51 modifier.    

I have never heard that a 51 modifier and 59 modifier could not be coded together.  I have a couple commercial payers that require both.  I normally code based off of the CPT guidelines unless I know the pt insurance then I code to the insurance guidelines when it comes to modifiers.


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## lcaskew1 (Mar 21, 2015)

Thank you Misty. That was so helpful!


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