Cardiology Coding Alert

To report failed pacemaker and automatic internal cardioverter defibrillator (AICD) implantation procedures, try zooming in on the pacemaker type.

See if you can underline the necessary information in the procedure note and determine the correct codes for this patient's operation.

Case: The patient is a 69-year-old woman with an arrhythmic-related cardiac arrest. She has an extensive history of heart disease as well as prior cardiovascular surgery including pacemaker placement in 2005. A cath, which the physician performed earlier, revealed normal coronaries. The cardiologist then tested the existing pacemaker and found several episodes of sustained ventricular tachycardia. Based on these findings, the cardiologist decides to place an implantable cardioverter defibrillator (ICD).

Because the patient had very little subcutaneous tissue or muscle tissue in the pectoral regions, the cardiologist elected to place the system in the abdomen.
Using Xylocaine 1% local anesthesia, the physician made a left delta pectoral incision and a cephalic vein cutdown. Then he introduced the Medtronic ICD lead Model 6945 (100 cm). The physician secured the lead to the underlying subcutaneous tissue and a loop made in the delta pectoral region. Then he anchored another sleeve.

He tunneled the lead down to the abdomen where the physician made an incision using blunt dissection. He fashioned a pocket and irrigated it with antibiotic solution. He connected a Medtronic Gem 7227CX ICD and then placed in the abdominal pocket and anchored to the underlying subcutaneous tissues.

He closed the subcutaneous tissue and subcuticular tissue. Prior to closure of the skin sutures, he performed a V-fib induction. The first episode of ventricular fibrillation failed at 8 joules, but at 14 joules was successful in converting the rhythm to sinus.

The physician created a second episode of ventricular fibrillation and terminated promptly to sinus rhythm with a 14-joule shock.

Then the cardiologist turned his attention to the removal of the existing pacemaker system. The lead, with its significantly reduced impedance, was a problem. In addition, the atrial lead was nonfunctional, given the patient's chronic atrial fibrillation. The physician made an incision over the area of the existing generator and carefully explanted it. He capped the leads, then secured and placed them back in the pocket. He irrigated the existing pocket using antibiotic solution.

There were no complications, and the patient left the cardiovascular lab in satisfactory condition.

Before you delve into the coding process, you should make certain you know which device the cardiologist describes in the note.

Why: "Many times I see physicians using the terms 'pacer' and 'AICD' interchangeably. It really does make a difference when you are coding them," says Cheryl Klarkowski, RHIT, CPC, coding specialist for Baycare Health Systems in Green Bay, Wis.

Therefore, you should "know the type of device the cardiologist implants, understand the functions of this type, and how the cardiologist uses it," says Christina Neighbors, MA, CPC, charge capture reconciliation specialist for Franciscan Health Systems in Tacoma, Wash. For instance, if you're dealing with a pacemaker, you need to know if it is a single or dual one. That is not the case for an AICD.

Now, the real coding begins.

In the case study above, the note describes the insertion of a complete cardioverter-defibrillator system with leads. The cardiologist introduced the new lead and tested it, then secured it in place. He formed a tunnel to bring the lead from the cephalic vein area through the abdomen, where he also formed a new skin pocket to place the new cardioverter-defibrillator.

Solution: Therefore, the CPT code for the placement of the new system is 33249 (Insertion or repositioning of electrode lead[s] for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator). "This code is OK for the insertion of the new AICD," Klarkowski says.

You should include the creation of a pocket in the placement of the AICD (33249). That means you do not require a pocket revision code, Klarkowski adds.

Keep in mind: If the cardiologist inserted a new defibrillator unit into the original skin pocket and attached the unit to existing leads, use 33240 (Insertion of single or dual chamber pacing cardioverter-defibrillator pulse generator).
Next, the chart note describes how the physician tested the new system. You can separately report this with 93641 (Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation [induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination] at time of initial implantation or replacement; with testing of single or dual chamber pacing cardioverter-defibrillator pulse generator).

Finally, once the new system's installation was complete, the cardiologist removed the old pacemaker and left the old leads in place in the original pocket. Indicate this service with 33233 (Removal of permanent pacemaker pulse generator).

Watch out: To "cap a lead" does not mean removing it, so you should not report 33235 (Removal of transvenous pacemaker electrode[s]; dual lead system), Klarkowski says. Also, you should not use 33241 (Subcutaneous removal of single or dual chamber pacing cardioverter-defibrillator pulse generator) because this code describes the removal of an AICD, not a pacemaker.

Heads up: If the cardiologist removes the complete pacemaker system, including the leads, use 33233 for the generator removal and 33235 for the leads removal.

Don't code what isn't there: Although cardiologists typically perform fluoroscopy during this procedure, in this case you shouldn't bill it. You have no indication within the note that the physician used fluoroscopy.

Modifiers: First, you should code the primary procedure as 33249 (insertion of ICD), because this has the highest relative value units (RVUs). If your payer requires modifier 51 (Multiple procedures), be sure to append it to 93641 (defibrillation test) and 33233 (PM generator removal). You'll also use modifier 26 (Professional component) on 93641 to reflect that you are billing only the physician portion of the service.

ICD-9 code: For the ventricular tachycardia, use 427.1.

Therefore, coding for this procedure would appear as follows:
Diagnosis codes
427.1

Procedures
33249-26
33233-51
93641-26-51.

Bonus: You could consider also adding modifier 22 (Increased procedural services) to the defibrillator implantation code (33249). The typical defibrillator implantation involves creation of a skin pocket in the sub-clavicular region (where there is a direct path between the leads and the pocket). Because this procedure involved an abdominally placed generator and lead tunneling (a surgically created tunnel connecting the generator [in the abdomen] to the leads [in the patient's chest]), it certainly warrants using this modifier.