Cardiology Coding Alert

Plus: Watch for which typical service isn't mentioned at all.

Challenge yourself with this real-life case study to see if you can pinpoint the codes this documentation does -- and doesn't -- back up.

Begin by Analyzing the Report Excerpt

An incision was made along the left deltopectoral groove, and an ICD pocket was dissected out, was prepared with extensive dissection.

Three separate guidewires were advanced into the left subclavian vein using the Seldinger technique across the open pocket. The middle of these wires was then used to advance a coronary sinus sheath for placement of the left ventricular lead. With some difficulty, we were finally able to advance the coronary sinus sheath in the mid coronary sinus and an angiogram was obtained. A left ventricular lead was then advanced in the lateral cardiac vein and the tip was advanced to the near LV apex. Electrical testing was done at 3 separate locations and the rest of these noted a lead impedance of 840 ohms and an R wave value of 17.1 mV.

Next the bipolar right ventricular defibrillator active fixation lead was advanced to the right ventricle, several areas were checked and the lead was finally fixated along the RV.

Next the bipolar right ventricular defibrillator active fixation lead was advanced to the right atrium. Several areas checked and the lead was finally fixated along the RV septum and tested.

Next a bipolar screw in type right atrial lead was advanced to the right atrium and the lead was fixated to the right atrial wall. The coronary sinus sheath was then removed with the cutting device maintaining a good lead position of the LV lead.

All 3 leads were then sutured to the pectoral fascia over the Silastic sleeves. The pocket irrigated. The leads were thenattached to the ICD/BiV device. The ICD was then placed in the pacer pocket after a standard dose of thrombin material in the pocket. Pocket was then sutured closed.

The patient was given propofol and the following establishment of adequate general anesthesia. Ventricular fibrillation was induced. The advice analyzed and delivered 3 separate DC countershocks, at last at 36V and the patient converted back to normal sinus rhythm. Patient was awakened from sedation without obvious side effects.

Find Your First Stop at an Add-On Code

The case study "appears to be a new implant of a Biventricular Defibrillator with follow-up testing at implant," says Sandy Fuller, CPC, MCS-P, a Texasbased cardiology coding expert.

While making your way through the first two paragraphs, you should focus on the terms describing placement of the left ventricular lead via the coronary sinus. The correct code for this portion is +33225 (Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverterdefibrillator or pacemaker pulse generator [including upgrade to dual chamber system] [List separately in addition to code for primary procedure]), says Fuller.

Documentation tip: You may see this lead referred to as either a left ventricular (LV) lead or coronary sinus lead, says Jennifer Crowell CPC, CCC, CEMC, Lead Coder/Lead Hospital Coordinator for Spokane Cardiology in Washington.

Add the Primary Code for That Add-On Code

The next few paragraphs of the documentation describe lead fixation for the right ventricle (RV) and the right atrium (RA). The cardiologist also attaches the leads to the device, places the device in the pacer pocket, and sutures the pocket closed. All of this is covered by one code, says Crowell: 33249 (Insertion or repositioning of electrode lead[s] for single or dual chamber pacing cardioverterdefibrillator and insertion of pulse generator).

Add-on note: CPT lists 33249 as an appropriate primary code for add-on code +33225, Fuller says. Remember that "add-on codes are always performed in addition to the primary service or procedure and must never be reported as a stand-alone code," according to CPT's "Instructions for Use of the CPT Codebook."

Defib Testing Earns the Final Code

The last paragraph of the case study excerpt describes 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), says Fuller.

With defib testing, you want to see impedance in the documentation, says Crowell. "Usually [physicians] will state something like, 'Ventricular fibrillation was induced. The device analyzed and delivered 3 separate DC countershocks, at last at 36V and the patientconverted back to normal sinus rhythm. The high-voltage impedance was 45 ohms,'" she explains.

Term tip: The defibrillation threshold (DFT) is the minimum energy amount needed during ventricular arrhythmia to defibrillate the heart reliably, Crowell says. Knowing the patient's DFT helps the cardiologist confirm that the cardioverter-defibrillator (ICD) programming will provide enough of a shock to defibrillate the patient's heart.

Append Modifiers to at Least 1 Code

Code 93641 requires modifier 26 (Professional component) to indicate you're claiming only the physician work (and practice expense and malpractice expense) for this service. The Medicare Physician Fee Schedule lists a PC/TC indicator of "1" for this code. That means you may use modifier 26 with the code.

"You should not need a modifier on 33225 because it is an add-on code for 33249," says Fuller. But "you may need a 59 modifier on the 93641, depending on the carrier. You shouldn't need one, but you never know with carrier's software," she adds.

Be Sure Your Practice Hits These Points

In a case like this, the physician normally would use fluoroscopy, as well, but it's not documented in this case, says Fuller.

No documentation of fluoroscopy means you should not bill fluoroscopy, says Crowell. When fluoroscopy is documented, you should report 71090-26 (Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation).

ICD-9: The case-study excerpt also doesn't mention indications for you to choose ICD-9 diagnosis codes, says Crowell. "Without a VT [ventricular tachycardia] diagnosis or information relating to primary prevention criteria, this cannot be coded. You either have to have a payable diagnosis for the ICD or data to support adding a Q0 modifier [Investigational clinical service provided in a clinical research study that is in an approved clinical research study] to 33249," Crowell says.

Also check your local requirements for diagnosis codes that support medical necessity for 33225. For Crowell's Medicare carrier, she must include a specific congestive heart failure (CHF) code as the primary diagnosis and a conduction disorder as secondary. For example, your documentation may support coding heart block, bundle branch block, or similar disorders.

• Resources: CMS offers additional information on diagnosis coding: "Update to List of ICD-9-CM Diagnosis Codes Not Requiring the Q0 Healthcare Common Procedure Coding System (HCPCS) Modifier for Automatic Implantable Cardiac Defibrillator (ICD) Services Provided in a Clinical Study," www.cms.gov/transmittals/downloads/R663OTN.pdf 
• National Coverage Determination, publication 100-03, section 20.4, www.cms.gov/Manuals/IOM/list.asp.