Cardiology Coding Alert

Tip: Ask yourself if the lead is the same or different

Last month, you learned how to code AICD insertions, evaluations and upgrades -- but that's not the end of the story. You also need to know how to report the replacement of pulse generators and electrodes as well as the repair, repositioning and revision of an automatic internal cardioverter defibrillator.

Use 2 Codes for Battery Change

First, when the battery in the AICD's pulse generator nears the end of its life, the cardiologist will replace the pulse generator. In other words, he does a "battery change."

Rule of thumb: For this service, you'll report two codes -- one for the insertion of the new generator (33240, Insertion of single or dual chamber pacing cardioverter-defibrillator pulse generator) and one for the removal of the old (33241, Subcutaneous removal of single or dual chamber pacing cardioverter-defibrillator pulse generator).

Example: Your cardiologist sees a patient for a battery change. He explants the old dual-chamber AICD and inserts a new dual-chamber pulse generator. For this procedure, you should report 33240 and 33241. Note: Always list the highest valued code first. You may want to add modifier 51 (Multiple procedures) to 33241, depending on your payers' recommendations.

When you're looking for a diagnosis code to apply to this situation, you should use V53.32 for AICDs. "The code description states that it includes the removal of device, replacement of device. You should not use 996.0x [Mechanical complication of cardiac device ...] because a battery change is not an unexpected complication," says Inga Burton, CPC, certified coding specialist at Pima Heart Physicians PC in Tucson, Ariz.

Keep in mind: If your cardiologist replaces the entire AICD system (pulse generator and leads), you should report 33241 for the old pulse generator's removal, 33243 (Removal of single or dual chamber pacing cardioverter-defibrillator electrode[s]; by thoracotomy) or 33244 (Removal of a single or dual chamber pacing cardioverter-defibrillator electrode[s]; by transvenous extraction) for the lead(s) removal, and 33249 (Insertion or repositioning of electrode lead[s] for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator) for the new system's insertion.

Evaluate This Electrode Replacement Scenario

Battery changes aren't all you need to know about replacements. When an electrode malfunctions, your cardiologist may need to replace an AICD electrode. If so, your coding options are:

• 33216 -- Insertion of a transvenous electrode; single chamber (one electrode) permanent pacemaker or single chamber pacing cardioverter-defibrillator

• 33217 -- ... dual chamber (two electrodes) permanent pacemaker or dual chamber pacing cardioverter-defibrillator

• 33244 -- Removal of single or dual chamber pacing cardioverter-defibrillator electrode(s); by transvenous extraction.

Don't miss: In this situation, your cardiologist is going to handle two different leads. Like the changing-the-battery example above, you should report both the removal of the old lead(s) and the insertion of the new lead(s).

Example: Your cardiologist discovers that the right atrial lead of a patient's dual-chamber pacing AICD has stopped working properly, but the right ventricular lead is still functioning. Therefore, he removes the right atrial lead and inserts a new one. You should report 33216 and 33244.

Note: Not often, but sometimes the removal of transvenous leads requires a thoracotomy. If this is the case, you should report 33243.

Review These 3 AICD Repair Examples

On occasion, your cardiologist may reposition the same lead. If your cardiologist needs to repair, revise or reposition an AICD component without actually replacing it, you should choose from the following codes:

• 33215 -- Repositioning of previously implanted transvenous pacemaker or pacing cardioverter-defibrillator (right atrial or right ventricular) electrode

• 33218 -- Repair of single transvenous electrode for a single chamber, permanent pacemaker or single chamber pacing cardioverter-defibrillator

• 33220 -- Repair of two transvenous electrodes for a dual chamber permanent pacemaker or dual camber pacing cardioverter-defibrillator

• 33226 -- Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, insertion and/or replacement of generator).

Example 1: Your cardiologist repairs only one transvenous lead of a dual-chamber device. For this service, you should report 33220 with modifier 52 (Reduced services) appended.

Another modifier to keep in mind is modifier 78 (Return to the operating room for a related procedure during the postoperative period). If the patient returns to the operating room for a related procedure (such as repositioning the AICD) within the 90-day global period, you'll use this modifier, says Sarah Tupper, CMC, coder for Central New York Cardiology in Utica, N.Y.

Example 2: The cardiologist determines that the right ventricular lead of the patient's dual-chamber AICD dislodged. He goes back in within 90 days of the insertionprocedure to disconnect the lead from the generator, reposition and reconnect it. Pacing is restored. For this service, you'll report 33215-78.

Example 3: The patient's coronary sinus (left ventricular) lead of his biventricular AICD dislodges after 90 days of the insertion procedure. The cardiologist disconnects the lead from the generator, repositions and reconnects it. Pacing is restored. For this service, you'll report 33226.

Overall tip: "The Guidant Web site has several free Web casts that provide excellent direction for these procedures as well as CEU [continuing education unit] opportunities," Burton says.