Cardiology Coding Alert

Pacemaker leads frequently dislodge for a variety of reasons. The lead itself may not function properly, it may not have been installed correctly; or it can be dislodged by a fall or a sudden move by the patient. When this occurs, the patient must return to the operating room (OR) to have the leads repositioned.

If this occurs more than 15 days after the pacemaker was initially installed, the procedure can be billed using the following codes:

33216 insertion or repositioning of a transvenous electrode (15 days or more after initial
insertion); single chamber (one electrode)
permanent pacemaker or single chamber
pacing cardioverter-defibrillator, or

33217 insertion or repositioning of a transvenous
electrode (15 days or more after initial
insertion); dual chamber (two electrodes)
permanent pacemaker or dual chamber
pacing cardioverter-defibrillator.

Because the original implantation has a 90-day global period, modifier -78 (return to the operating room for a related procedure during the postoperative period) would need to be attached to either CPT 33216 or CPT 33217.

If the repositioning occurs before the 15th day of the global period, reimbursement is much harder to obtain, because the descriptors of 33216 and 33217 clearly state that the codes are for repositioning or reinsertion 15 days or more after the original implantation.

Some carriers will reimburse the procedure if the circumstances are unusual and the documentation indicates that the lead became dislodged through no fault of the physician.

That is not the case, however, in this case study.
The original pacemaker implantation took place on Sept. 4, 1999. The patient, who had a pre- and post-operative diagnosis of sick sinus syndrome (ICD-9 427.81), received a dual chamber pacemaker and tolerated the procedure well.

This operative session was coded as follows:

33208 insertion or replacement of permanent
pacemaker with transvenous electrode[s];
atrial and ventricular

71090 insertion pacemaker, fluoroscopy and
radiography, radiological supervision and
interpretation

Note: If fluoroscopy is performed by another physician (e.g., radiologist), it should not be billed.

Five days later, the patient is back in the OR because the atrial lead dislodged.

Operative Report

Preoperative Diagnosis: Dislodgement of atrial electrode; sick sinus syndrome
Postoperative Diagnosis: Same
Operation: Repositioning of atrial electrode
Indications: For treatment of the above

Procedure: The patient was prepped and draped in the usual sterile fashion. The pacemaker site was infiltrated with lidocaine. An incision was made through the wound of the pacemaker incision that was done just two days prior. The wound was carefully opened, and the pacemaker was explanted. The atrial electrode was then disconnected from the pulse generator and loosened as well as from the subcuticular fascia. The electrode was pulled back slightly to tighten the J curve at the distal end. This improved sensitivity significantly. P wave amplitudes ranged from 1.5 to 1.75 and, after the repositioning, P waves were between 3 and 3.5 mv. The resistance was 400 ohms, and the atrial capture threshold was 0.5 volts. The atrial electrode was then secured to the prepectoral fascia once again with 2-0 silk. The wound was checked for hemostasis with electrocautery and then the atrial electrode was reconnected to the pulse generator. The wound was then closed in two layers with a running 3-D Vicryl closure for the fascia and running 4-0 Vicryl subcuticular closure for the skin. The patient tolerated this procedure well and there were no complications.

Cause of the Dislodgement Isnt Documented

The repositioning of leads described in this op note is not a billable procedure, says Sueanne Bicknell, RRA, CPC, CCS-P, compliance administrator with CPR Heart Place, an 80-physician practice with 60 cardiologists and five electrophysiologists in Dallas.

Because the codes for pacemaker implantation include repositioning or replacement in the first 14 days after initial insertion of the device, the repositioning of the atrial lead eight days after the insertion should not be reported separately, Bicknell says.

The op note doesnt say there was a mechanical problem with the lead; rather, it notes that good lead checks were obtained at the time of implant, Bicknell says. The dislodgement may have been due to the patient moving or pulling, but we dont know, as there is no statement to this effect.

Furthermore, the CPT manual clearly states that pacemaker insertions include repositioning or replacement in the first 14 days after the insertion (or replacement) of the device.

Without any supporting documentation to indicate why the procedure was unusual and therefore should be billed, billing 33216 with modifier -78 would not be appropriate and might be considered fraudulent, Bicknell says.

Attaching modifier -22 (unusual procedural services) to code 33216 also is incorrect because the actual repositioning procedure was routine, Bicknell notes. Had there been a documented reason for the dislodgement that clearly showed it was due to circumstances beyond the control of the physician, some carriers may accept 33216 with modifier -78 attached, Bicknell says. Fluoroscopy (71090) also should be billed in these situations.

For example, if the lead dislodged because the patient fell, the operative note should state this and the claim should include this as supporting documentation, along with a note to the carrier asking that the 15-day guideline be waived because the situation was created by the patient and through no fault of the physician.

Even with a good reason and good documentation, most carriers are likely to deny the claim, citing the 15-day guideline, Bicknell says. But some carriers may pay in these circumstances, and Bicknell notes that you wont get paid if you dont ask.