Cardiology Coding Alert

Billing for the implantation and/or removal of implantable cardioverter-defibrillator (ICD) devices can be difficult. But with the revised procedure codes in CPT 2000, billing them step by step will gain proper reimbursement.

In what may be the most important revision, CPT 2000 specifically states that codes 33240-33249 should be billed for single- or dual-chamber insertions and/or removals. Previously, dual-chamber ICDs were not mentioned specifically, and providers could bill an additional fee for implanting or removing a dual-chamber device by adding modifier -22 (unusual procedural services) to the appropriate procedure code. Because the code now includes dual-chamber systems, modifier -22 should no longer be billed.

Although this change may cut reimbursement in some situations, the new wording better describes the ICD devices now in use by electrophysiologists. It is intended to address the rapidly changing technology of ICDs, some of which now combine dual-chamber pacing with cardioversion/defibrillation.

The implantable automatic defibrillator is an electronic device designed to detect and treat life-threatening tachyarrhythmias. Like pacer systems, ICDs have two components: a pulse generator and one or more electrodes. All modern ICDs have at least single-chamber backup pacing, but their main function is to treat ventricular tachycardia or fibrillation.

CPT codes 33240-33249 describe the insertion (implantation) and/or removal of either the pulse generator, the electrodes, or both. They are broken down as follows:

33240 insertion of single or dual chamber pacing cardioverter-defibrillator pulse generator
33241 subcutaneous removal of single or dual chamber pacing cardioverter-defibrillator pulse generator
33243 removal of single or dual chamber pacing cardioverter-defibrillator electrode(s); by thoractomy
33244 by transvenous extraction
33245 insertion of epicardial single or dual chamber pacing cardioverter-defibrillator electrodes by thoracotomy
33246 with insertion of pulse generator
33249 insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator

Codes 33216 (insertion or repositioning of a transvenous electrode [15 days or more after initial insertion]; single chamber [one electrode] permanent pacemaker or single chamber pacing cardioverter-defibrillator) and 33217 (insertion or repositioning of a transvenous electrode [15 days or more after initial insertion]; dual chamber [two electrodes] permanent pacemaker or dual chamber pacing cardioverter-defibrillator) have also been revised, and now apply both to pacemakers and ICDs. They are used for insertion of electrodes more than 15 days after a pulse generator is implanted.

Note: Codes 33243 and 33244 differ only in the method used to remove the electrodes. In 33243, a thoracotomy is performed so the epicardial leads (on the muscle of the heart) can be removed. With 33244, the electrodes are removed by transvenous extraction, which is more commonly used and does not require a thoracotomy.

Codes 33240-33249 are not bundled into each other, so when an ICD or one of its components is removed and/or replaced, each step of the total procedure may be billed as per its CPT description.

For example, if an electrophysiologist implants a new dual chamber ICD (attaching the leads transvenously) by removing the old pulse generator and lead (by venous extraction), the procedure should be coded as follows: 33249, 33244, 33241, 71090 (insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation), and 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).

Until CPT 2000, 93618 (induction of arrythmia by electrical pacing) could also be billed. This procedure now is bundled into 93641.

Note: Carriers vary on whether they require modifier
-51 (multiple procedures), so check with your carrier and find out if they require this modifier.

The removal of leads is a high-risk procedure that has significant morbidity associated with it because the ventricle may be damaged during the procedure. Unless there is a clear need for their removal, they are usually left where they are and attached to a new pulse generator once the old generator is removed. This would be charged as follows: 33240, 33241, 71090.

CPT Wording Unclear on Full ICD Replacement

Although the CPT 2000 revisions clarified the technological issues, awkward wording following CPT codes 33241 and 33249 has resulted in conflicting advice regarding the billing of complete ICD replacement.

According to CPT, For removal and reinsertion of a pacing cardioverter-defibrillator system (pulse generator and electrodes), report 33241 and 33243 or 33244 and 33249. Two very different interpretations have flowed from this confusing statement.

In a November 1999 article on the newly announced CPT 2000 changes, CPT Assistant , discussing revisions to 33243, stated, When a pacing cardioverter-defibrillator pulse generator and electrodes are removed and a new system is inserted, it is appropriate to code 33241, 33243 or 33244, and 33249.

When discussing revisions to 33249 on the following page, however, CPT Assistant states, For removal and reinsertion of a pacing cardioverter defibrillator system (pulse generator and electrodes), report 33241 and 33243; or 33244 and 33249.

The two interpretations in the November article are inconsistent, says Greg Schnitzer, RN, CPC, CPC-H, CCS-P, manager of coding compliance with CodeRyte, an artificial intelligence coding software firm in Bethesda, Md. Schnitzer, who says there is no reason to split 33241/33243 and 33244/33249, also adds that highlighting the split in June muddies the waters further.

Schnitzer agrees with our coding experts that 33241, 33243 or 33244, and 33249 would be the best way to code an ICD replacement without thoracotomy.

Note: Marko Yankovlevitch, MD, FACC, chief of cardiology at Northwest Hospital in Seattle; Terry Fletcher, BS, CPC, CCS-P, a coding and reimbursement specialist in Laguna Beach, Calif.; Gay Boughton-Barnes, MPC, CPC, CCS-P, a cardiology coding and reimbursement specialist in Tulsa, Okla.; Martha Gerant, CPC, a practice coder for Cardiology Services in Shawnee Mission, Kan.; and Cynthia Swanson, RN, CPC, a coding and reimbursement specialist with Seim, Johnson, Sestak & Quist, an accounting firm in Omaha, Neb., contributed to this article.