Cardiology Coding Alert

Discover what code to use for both single-and dual-chamber devices

Did you know you could lose out on reimbursement if your cardiologist isn't including necessary documentation for fluoroscopy in his implantable cardioverter-defibrillator (ICD) device note? Challenge yourself with this true/false quiz and find out if your ICD implant coding fits the bill.

Decide What ICD Implant Code You Need

Statement: When your cardiologist implants a new ICD system, you'll use the same code for single- and dual-chamber systems. True or false?

Answer: True.

You don't need to worry about distinguishing between single- and dual-chamber devices when the cardiologist implants a new ICD system, because implant procedure code CPT 33249 (Insertion or repositioning of electrode lead[s] for single- or dual-chamber pacing cardioverter-defibrillator and insertion of pulse generator) is for either single- or dual-chamber devices. So use this code for either system, says Sandy Fuller, CPC, compliance officer at Cardiovascular Associates of East Texas in Tyler.

Keep in mind: If your cardiologist implants a bi-ventricular device, you should include the add-on code +33225 (Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator [list separately in addition to code for primary procedure]), Fuller adds.
 
Test Your System Testing Knowledge

Statement: When the physician tests the system during an implant, the only code you need to report is CPT 93641. True or False?

Answer: False.

Bottom line: You've got to look carefully at your cardiologist's notes to determine whether he tested both leads and generator or the leads only.

When the physician tests the system during an implant, report 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). This includes the leads and generator, Fuller says.

On the other hand, 93640 (Electrophysiologic evaluation of single- or dual-chamber pacing cardioverter-defibrillator leads ...) is for lead testing only.

"I have used 93640 on an initial placement because the doctor only tested the leads on the system; he did not want to test the generator for fear the patient's heart had an intra-cardiac clot," says Sandra D. Combs, CPC, medical coder at Midwest Cardiovascular Specialists in Mishawaka, Ind.

Don't Leave Out EP Evaluation

Statement: You should refrain from using 71090 for fluoroscopy at the time of the ICD implant because the definition only mentions pacemakers. True or false?

Answer: False.

Typically, you will report fluoroscopy at the time of ICD implant the same way you report fluoroscopy for pacemaker implants--with 71090 (Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation). Although 71090's definition mentions only pacemakers, the AMA confirms that it is the appropriate code to report for ICD implants as well.  
   
Indeed, the AMA's CPT Assistant (August 2002) states that "CPT code 71090 ... is intended to be used with pacemakers or cardioverter-defibrillators."

Fluoro tip: Your physician will likely use fluoroscopy to visualize the leads' advancement into the appropriate location but won't always note this in the operative report. If you find that your physicians do not clearly document fluoroscopy, make sure you inform them that this is a separately billable/reimbursable service, but only if their operative reports support it. 
 
In other words, "if the term 'fluoroscopic guidance' is absent from your cardiologist's note, you should not bill it," Fuller says. "Otherwise you don't have the necessary documentation to report it."

Code 71090 has a global, technical, and professional fee allowance. If the physician is billing for the professional component (modifier 26), you must have documentation available to support the test's supervision and interpretation. "In that case, the hospital would bill the technical component (modifier TC) portion," Combs says.