# Unusual single ICD to Bi-Vent upgrade



## jtuominen (Apr 1, 2009)

Hi there-- having alot of trouble on this single ICD upgrade to Bi-Vent.
Wondering what others may code for this case-- I am inclined to the following codeset but I keep running into a device edit with the 33225 because there is no C1900 on the claim. The dictation reads like no bi-vent lead was placed because there was already one existing? Really confused! I think I may go back to the doc for clarification, or perhaps the wrong device code was applied, but wondering what you all thought about it. Here are the codes I am thinking of right now:

33240
33241
33225
33216 

Devices
C1882
C1779




PROCEDURE: 
1.  Implantation of a new atrial lead. 
2.  Upgrade of a single-chamber ICD to a biventricular ICD. 

INDICATION:  Severe LV dysfunction with left bundle branch block. 

HISTORY OF PRESENT ILLNESS:  This is a delightful 42-year-old 
gentleman with a history of severe ischemic cardiomyopathy who 
recently had a single vessel bypass with the epicardial LV lead 
implanted at that time.  His LV function improved from 10-20%.  He 
does have a left bundle branch block greater than 120 milliseconds.  
The patient is a New York Heart Class III and therefore would fit the 
criteria for upgrade of his device to a biventricular ICD. 

METHOD:  After obtaining informed consent, the patient was prepped 
and draped in the usual fashion.  Intravenous antibiotics were given.  
Conscious sedation was administered.  1% lidocaine was infiltrated 
into the incision located below the mid left clavicle.  An incision 
was made with a #15 blade.  The device was then removed from the 
pocket and leads detached from the device.  Under fluoroscopy, there 
was one LV lead implanted epicardial lead that was bifurcated into 
two different epicardial positions.  Despite multiple attempts, I was 
unable to locate the tip of this lead.  Therefore, Dr. _______ came 
in to assist the procedure.  It was quite medial to the prior ICD 
incision.  An incision was made over this area and the lead was 
identified.  Appropriate sensings and threshold were obtained.  There 
was no diaphragmatic stimulation at high output pacing. 

The left subclavian vein was then accessed using Seldinger technique.  
A 6 French sheath was introduced into the subclavian vein.  A lead 
was then advanced to the heart and was fixed to the right atrial 
appendage.  Appropriate sensings and threshold were obtained.  There 
was no diaphragmatic stimulation on high output pacing.  The sheath 
was then peeled away.  The lead was then secured onto pectoral muscle 
using 0 Ethibond sutures. 

The pocket was then irrigated with bacitracin solution.  The leads 
were then attached to the new device and placed in the pocket.  Both 
pockets were then closed with 2-0 and 4-0 Vicryl sutures.  
Steri-Strips and OpSite dressing were then placed over the incision.  
Intraoperative defibrillation testing was then performed.  The 
patient was transferred back to the care suite in stable condition. 

Biventricular ICD generator:  St. Jude Atlas V-366, 459065. 

Replaced generator:  St. Jude V-168, 370500 (11/23/2007). 

LEAD INFORMATION: 
1.  RA, 1888TC-52 cm, BCG29495. 
2.  RV, 7020-65, ADK11026 (11/23/2007). 
3.  LV Medtronic 4968-60, LEN060250R (11/22/2008). 

STIMULATION THRESHOLD: 
1.  RA:  Measured at 2.5 mV, capturing at 0.75 volt at 0.5 
milliseconds, 414 ohms. 
2.  RV:  Measured greater than 12 mV, capturing at 1 volt at 0.5 
milliseconds, 270 ohms. 
3.  LV:  Measured greater than 12 mV, capturing at 1.5 volts at 0.5 
milliseconds, 620 ohms. 

Fluoroscopy time:  5.12 minutes. 

COMPLICATIONS:  None. 

CONCLUSIONS: 
1.  Uneventful implantation of a new right atrial lead. 
2.  Uneventful upgrade of a single-chamber ICD to a biventricular 
ICD. 
3.  Defibrillation threshold is at or below 25 joules, greater than 
or equal to 10 joules safety margin.


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## deeva456 (Apr 1, 2009)

HELLO,

I read your report and the codes you are using are not correct. Billing with 33240 & 33225,33216 is the problem. Using these 3 codes you are actually unbundling 33249.

The correct codes to use as documented in your report are: 

33241- removal of a single/dual chamber pacing ICD generator
33249 - *Insertion *or repositioning of *electrode lead*(s) for a single or dual chamber ICD *and insertion of pulse generator*
71090-26 - insertion of pacemaker/ICD fluoroscopy
93641-26 - testing of single or dual chamber pacing ICD generator

When coding for a replacement of generator or leads or upgrading from a single to dual chamber pacemaker or ICD you only bill what you put in. Since a new generator and 1 lead was implanted 33249 is the correct code to use. 

71090-26 "under fluoroscopy" was stated. Since the MD mentioned he used fluorscopy during this procedure you can bill for this.  All pacemaker and ICD reports must indicate use of fluoroscopy in order to bill for it. 

93641-26- MD tested the generator and you can also bill for this. Report should indicate testing was done in order to bill.  93614-26 is for testing of the generator during the procedure. 

I have a question above the device codes you use.  Our EP has never used the C codes. I have never heard of billing C codes. why or how are they used? 

I hope this information has been helpful and I appreciate your feedback about the C codes.

have a great day,

Dolores, CPC, CCC


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## jtuominen (Apr 1, 2009)

Thanks much for the information. I knew something must be up so I am glad to get the feedback on this one. It will be interesting to explain it to the cathlab. 

I just listed the HCPCS device codes because my encoder/editor was telling me that they were the source of the problem with the codeset I was choosing. I keep an eye on all the C codes for all the cathlab procedures because sometimes they get mixed/up or not reported on the claim. They are the codes that identify what types of supplies and devices were used, and some are directly tied to CPT procedure codes. 

For example, when a double chamber pacemaker is inserted (lets just say 33208, 71090) the corresponding C code that "maps" to code 33208 is C1785. (C1785 = pacemaker, dual chamber, rate-responsive). If that code isn't on the claim then you will get edits. Some common c codes for EP studies that I find are C2630 (3D mapping catheter), C2629, C1731, C1733, etc.

Thanks very much for the info, Dee!


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## deeva456 (Apr 1, 2009)

Very interesting information about the C codes. We have never used them nor has any of our payers have denied payment or asked the C codes to be listed on the claim. C codes are not required for professional charges on the pacemaker or ICD implants. But if you have a payer that requires it then I guess you can use them. 

Thanks for the info.


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## jtuominen (Apr 1, 2009)

I actually work on the hosptial side for the cardiology department. We have a strange setup where for statistical/financial accounting purposes we use CPT codes in our charge entry to system to keep track of what procedures were performed, and our cathlab has mapped all their supplies to respective c codes. It is a very interesting facet of coding I never knew about until I took this position. Would love to entertain any other questions about them if you have any. Thanks!


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