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Location over function leads code selection for his bundle and left bundle branch pacing.

As technology continues to advance, the challenges surrounding procedural coding for pacemakers and implantable cardioverter defibrillators (ICDs) continue to grow. The most commonly used systems are transvenous, where leads are fixated in the heart’s chambers and connected to a generator implanted in the chest that provides power.

Although these systems have been the standard for decades, advancements are being made that aim to improve treatment quality and patient outcomes. Conduction system pacing, using the bundle of His or left bundle branch, is one of these advancements. While this concept may be new, you are likely already familiar with the codes that are applied for these procedures.

First, Understand the Anatomy and Physiology

Before tackling procedure coding, it’s essential to have a solid understanding of the anatomy of the cardiac conduction system. Electrical impulses travel through specialized cells in the heart, a process that leads to the contractions that result in blood being pumped throughout the body. The electrical impulses originate from the sinoatrial node, which is located in the right atrium.

The impulse then spreads through both atria, causing them to contract, before reaching the atrioventricular node. The atrioventricular node is located near the bottom of the right atrium close to the central portion of the heart in an area called the triangle of Koch. From here, impulses travel through a segment of fibers called the bundle of His before splitting into the left and right bundle branches in the ventricles. The signals terminate in the Purkinje fibers, which results in ventricular contraction.

Complications within the conduction system may result in impulses traveling in an irregular manner, becoming delayed, or stopping entirely. These complications lead to abnormalities in heart rhythm or rate and are known as arrhythmias. Pacemakers and ICDs are used to correct or treat arrhythmias. Pacemakers use low-level impulses to help maintain a steady heartbeat. Most new ICDs have the same functionalities as a pacemaker, in addition to being able to detect more life-threatening arrythmias and deliver shocks that area capable of essentially restarting the heart and restoring rhythm.

Become Familiar With Lead Placement

Traditional lead placements are in the right side of the heart. In single-chamber pacing, a lead is implanted in either the right atrium or the right ventricle. In dual-chamber pacing, leads are implanted in the right atrium and right ventricle. Biventricular pacing, also known as cardiac resynchronization therapy (CRT), involves the placement of leads in the right side of the heart as well as a left ventricular lead. Although right ventricular pacing has historically been the standard, it does often lead to complications including, but not limited to, ventricular dyssynchrony and valve regurgitation. According to the American Heart Association, there is a need for alternative pacing techniques. As a result, conduction system pacing is growing in popularity.

His bundle pacing may be selective or nonselective. In selective pacing, the lead is placed directly at the bundle of His. In nonselective pacing, also known as para-Hisian pacing, the lead is placed in nearby ventricular tissue. His bundle pacing can be limited by highcapture thresholds and a reduction in battery life, which has led to studies comparing its effectiveness to left bundle branch pacing. Left bundle branch leads are transventricular, meaning that entry is through the right atrium and the lead is fixated in the muscular septum where the left bundle branch can be stimulated.

The driving factor for coding these two types of leads will be location as opposed to function. In proximal His bundle implants, the lead is positioned on the atrial side of the tricuspid valve and would be coded the same as a right atrial lead. Distal His bundle lead placements are within the ventricular septum and would be coded the same as a right ventricular lead.

For example, an implant of a new dual-chamber pacemaker with an additional His bundle pacing lead would be coded as 33208 (Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular). Although three leads were placed, two of these leads were in the right ventricle. The descriptor for code 33208 includes electrode(s), indicating that more than one may be placed in a chamber. Code 33208 would also be used if only the His bundle lead was placed in conjunction with the right atrial lead.

Left bundle branch leads are placed in the ventricular septum through the right ventricle, so they would also be treated as a right ventricular lead. While codes do exist for left ventricular pacing, it is important to be mindful that these codes require specific placement locations. Codes 33224 (In this procedure, the provider introduces an additional pacing electrode for left ventricular pacing through a vein and advances it to the left ventricle. He attaches the electrode to an existing pacemaker or implantable defibrillator. He may also revise, remove and insert, or replace the existing impulse generator. The provider performs this procedure in patients with a high risk of heart failure who need biventricular pacing to help keep the heart beat in balance.) and 33225 (In this add–on procedure, the provider introduces an additional pacing electrode for left ventricular pacing through a vein and advances it to the left ventricle at the same time as he inserts an implantable defibrillator or pacemaker pulse generator. The provider performs this procedure in patients with sick sinus syndrome, arterioventricular block, or both, with the goal to upgrade the pacemaker to a dual chamber system.) specifically indicate placement must be in the coronary venous system. This is most often done via the coronary sinus.

Consider Use of Modifier 22 in Certain Situations

Although additional placements of His bundle and left bundle branch leads may not be separately reportable when multiple leads are placed in the same chamber, if the placement requires additional work, it is permissible to append modifier 22 (Increased Procedural Services) if documentation supports it. Modifier 22 is appended when a procedure requires additional time, effort, or work above and beyond what it normal.

For example, a provider intends to implant a defibrillator system for CRT. The right atrial and ventricular leads are implanted successfully, but there are complications with placement of the lead in the coronary sinus due to variant anatomy. The additional work takes 90 minutes before the provider ultimately decides to abort the coronary sinus lead and inserts a left bundle branch lead instead. In this case, a coder could consider reporting code 33249 (Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual chamber) with modifier 22 appended. As with the above pacemaker example, this code includes situations when multiple leads are placed in the same chamber.

 In conclusion, as advancements in pacemaker and ICD technology continue to evolve, it’s essential for coders to stay updated on these complex procedures. Conduction system pacing introduces new coding challenges, particularly with respect to lead placement and location. Understanding the nuances of these techniques and their impact on coding will ensure proper reimbursement.

By mastering the coding guidelines for these emerging technologies and applying the appropriate modifiers when necessary, coders can navigate coding challenges with confidence and precision.

Brittany Sowards, BA, CPC, CPMA, CCC, CCVTC,
Professional Coding Auditor/Educator at West Virginia University Medicine