Cardiology Coding Alert

Report 33233 for the removal of a permanent pacemaker pulse generator.

Pacemakers can be a challenging procedure to code. You must check the medical documentation for details as whether the pacemaker system is leaded or leadless and what you should do when your cardiologist changes the battery.

Read the following tips to learn how to report tricky pacemaker scenarios you may encounter in your cardiology practice.

Tip 1: Rely on This Code for Leadless Pacemaker System Insertion

CPT^® gives you a specific code to turn to when your cardiologist inserts or replaces a right ventricular permanent leadless pacemaker via a transcatheter.

Coding example: Your cardiologist makes an incision into the patient’s femoral vein and inserts a catheter up through the circulation into the right ventricle of the heart. He then inserts an initial permanent leadless pacemaker through the catheter into the ventricle. Finally, he removes the catheter.

You should report 33274 (Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed) for this scenario.

Leadless cardiac pacemaker system defined: A leadless pacemaker is a cylindrical device usually implanted in the endocardium (inner wall) of a ventricle that can both sense heart rate and rhythm and stimulate contractions.

A leadless pacemaker consists of a generator with a built– in battery and electrode the cardiologist inserts using a catheter with no wires to connect it to a monitor. The leadless pacemaker communicates via magnetic, ultrasound, or electrical waves for device evaluation and programming.

Tip 2: Changing Leaded Pacemaker System Battery Same as Changing Pulse Generator

In some situations, your cardiologist may change the battery in the patient’s pacemaker system with leads of implantable defibrillator. In these cases, when your cardiologist changes the battery, they are actually changing the pulse generator, per the CPT^® guidelines.

You may encounter several types of scenarios in this situation.

Example 1: Your cardiologist removes the pulse generator of a permanent pacemaker. You should report code 33233 (Removal of permanent pacemaker pulse generator only).

Example 2: Your cardiologist removes the pulse generator of an implantable defibrillator. You should report code 33241 (Removal of implantable defibrillator pulse generator only).

Example 3: Your cardiologist removes a permanent pulse generator and replaces it, but he does not replace any right atrial or right ventricular leads. The medical documentation indicates this is a single lead pacemaker system. You should report code 33227 (Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single lead system) in this case. You cannot report the pulse generator removal (codes 33233 or 33241) separately in this scenario.

Example 4: Your cardiologist inserts a new pulse generator. Existing multiple leads were already in place, and your cardiologist did not remove a prior pulse generator. You should report code 33221 (Insertion of pacemaker pulse generator only; with existing multiple leads) for this service.

Example 5: Your cardiologist inserts a new permanent pulse generator with one right atrial lead. You should report code 33206 (Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial) for this service.

Tip 3: Handle Revision of Pacemaker Skin Pocket Like This

In some cases, your cardiologist may have to revise a pacemaker’s skin pocket. According to the CPT^® guidelines, this skin pocket revision is included in codes 33206-33249 (Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual chamber), 33262 (Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; single lead system)-33264 (… multiple lead system), and 33270 (Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed)-33273 (Repositioning of previously implanted subcutaneous implantable defibrillator electrode), so you can would only report this procedure if it was not performed during one of the primary procedures (33206-33249, 33262-33264, and 33270).

On the other hand, if your cardiologist revises a skin pocket that involves incision and drainage of a hematoma or complex wound infection, you would look to codes 10140 (Incision and drainage of hematoma, seroma or fluid collection), 10180 (Incision and drainage, complex, postoperative wound infection), and 11042 (Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less)-+11047 (Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)).

Tip 4: Focus on Relocation of Pacemaker Skin Pocket

In some cases, your cardiologist may also need to relocate a skin pocket for a pacemaker or implantable defibrillator if the patient has infection or erosion.

“Relocation of an existing pulse generator may be performed as a stand-alone procedure or at the time of a pulse generator or electrode insertion, replacement, or repositioning,” according to CPT^®. “When skin pocket relocation is performed as part of an explant of an existing generator followed by replacement with a new generator, the pocket relocation is reported separately.” Note: If the cardiologist performs skin pocket relocation, this service includes all of the work associated with the original pocket, along with creating the new pocket.