Cardiology Coding Alert

Hint: Understanding RS&I coding is the key to denial prevention.

The huge number of changes to CPT®'s pacemaker (PM) and implantable cardioverter-defibrillator (ICD) section is challenging even veteran coders. You can simplify the switch by breaking the changes into manageable chunks and mastering one group before moving to the next. This article will focus on changes to 33202-33211.

Verify Provider Before Reporting 33202-33203

When reviewing 33202-33211 in the 2012 manual, the first change you'll notice is a revision to the parenthetical note following 33202-33203 (Insertion of epicardial electrode[s] ...). Compare the 2011 and 2012 versions of the note:

• 2011: "When epicardial lead placement is performed by the same physician at the same session as insertion of the generator, report 33202, 33203 in conjunction with 33212, 33213, as appropriate."
• 2012: "When epicardial lead placement is performed with insertion of the generator, report 33202, 33203 in conjunction with 33212, 33213, 33221, 33230, 33231, 33240."

The main change to the instruction is the list of codes you may report in conjunction with epicardial lead placement codes 33202 and 33203. The longer list is the result of CPT® 2012 adding and revising a number of codes for the insertion of a PM pulse generator (33212, 33213, 33221) or the insertion of a pacing ICD pulse generator (33230, 33231, 33240).

Practical application: Typically, cardiologists don't place epicardial leads themselves, says Terry A. Fletcher, BS, CPC, CCS-P, CCS, CEMC, CCC, CMSCS, CMC, of Terry Fletcher Consulting in Laguna Beach, Calif.

As CPT® 2012 guidelines explain, positioning electrodes (leads) on the epicardial surface requires a thoracotomy or thoracoscopic placement. You may be more likely to see a surgeon perform those services than a cardiologist. If your physician did not perform the epicardial lead placement, you should not code the service.

33206-33208 Join Other Codes for Full Replacement

The next change you'll notice for this code range is a revision to 33206-33208. CPT® 2012 adds the following bold text to the definitions: "Insertion of new or replacement of permanent pacemaker with transvenous electrode(s) ..."

What stays the same: As in 2011, the codes differ based on the electrode location:

• 33207, ... ventricular
• 33208, ... atrial and ventricular.

Also just as in 2011, 33206-33208 "include subcutaneous insertion of the pulse generator and transvenous placement of electrode[s]," according to a parenthetical note with the codes.

What's new: CPT® 2012 adds two additional parenthetical notes for these codes:

"For removal and replacement of pacemaker pulse generator and transvenous electrode(s), use 33233 [Removal of permanent pacemaker pulse generator only] in conjunction with either 33234 or 33235 [Removal of transvenous pacemaker electrode(s) ...] and 33206-33208"

"Do not report 33206-33208 in conjunction with 33227-33229 [Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator ...]."

Practical application: The first new note above clarifies that when the cardiologist removes a pulse generator and electrode(s) and then inserts a new generator and electrode(s) at the same session, you should report multiple codes.

For example, suppose that in a single encounter the physician performs the following:

Removes a pacemaker pulse generator (33233)

Removes one right atrial lead and one right ventricular lead (33235)

And then inserts a new pulse generator, a new right atrial lead, and a new right ventricular lead (33208).

The second new parenthetical note tells you not to report the total system insertion/replacement codes (33206-33208) in conjunction with the battery (pulse generator) change codes 33227-33229. Both sets of codes include battery insertion. As a result, reporting a code from each set would be the same as reporting a single battery insertion twice, which would be incorrect.

Scratch 71090 Off Your Coding Aids

One code you may have noticed missing from the above discussion is 71090 (Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation). The reason is that in 2012 "radiological supervision and interpretation related to the pacemaker or pacing cardioverter-defibrillator procedure is included in 33206-33249," according to CPT® guidelines. In fact, 71090 is no longer a valid code in 2012.

Example: In 2011, you would have reported dual lead pacemaker insertion under fluoroscopy using 33208 and 71090. In 2012, you'll report that same service using only 33208.

"The deletion of fluoroscopy when placing devices is another example of inclusion for routine services. Fluoro is needed to place the PM or ICD so CPT® may have rationalized that it is a component part of the service and not separately billable," says Fletcher.

CPT® has increasingly been creating these sorts of inclusions over the last four years or so, says Fletcher. "Cardiology has been especially hit because of 'routine' billing of components for general services." For example, echocardiography now includes "Doppler and color flow, nuclear SPECT scans now include ejection fraction and wall motion, and most recently the cardiac catheterization codes now include coronary injections, left ventricle injections, and the supervision and interpretations," she notes.

These sorts of all-in-one codes can result in decreased reimbursement. You can help your practice get every legitimate dollar by applying the new codes correctly, which helps avoid the costly man hours required to appeal denials.

Coding updates: Cardiology Coding Alert will continue covering CPT® 2012 changes over the next several months.