Cardiology Coding Alert

CPT 2003, which goes into effect Jan. 1, brings substantial changes for the cardiology coder, including three new codes and one revised code that will alter the way you report the insertion and repositioning of pacemaker and pacing cardioverter-defibrillator systems.

In addition, the 2003 version has two new codes for septal defect closure and some wording changes that will affect the way you apply existing codes.

CPT 2003 adds two new codes for repositioning previously implanted pacemaker electrodes and makes a major change to the time frame for billing for electrode insertion. The two new codes for repositioning previously implanted electrodes include:

33215 Repositioning of previously implanted transvenous pacemaker or pacing cardioverter-defibrillator (right atrial or right ventricular) electrode

33226 Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, insertion and/or replacement of generator).

You should use 33215 for repositioning the right ventricular or right atrial electrodes and 33226 for repositioning the cardiac venous electrode, advises Nikki Vendegna, CPC, a cardiology coding and reimbursement specialist in Overland Park, Kan.

But theres even bigger news for cardiology coders in a revision to 33216, which will allow you to bill for repositioning electrodes within 14 days. This is a major change, Vendegna stresses. Prior to the revision, you could not bill for electrode repositioning until 15 days after insertion.

The revised description in CPT 2003 states:

33216 Insertion of a transvenous electrode; single chamber (one electrode) permanent pacemaker or single chamber pacing cardioverter-defibrillator.

In addition to deleting the phrase "15 days or more after initial insertion" from the 2002 version, the new version of 33216 also deletes "repositioning" in reference to transvenous electrode placement.

In turn, the deletion of "repositioning" in 33216 also removes the term from its companion code 33217 (dual chamber [two electrodes] permanent pacemaker or dual chamber pacing cardioverter-defibrillator), which covers dual chamber electrode placement.

What this means is that you should use 33216 and 33217 just for insertion and not for repositioning, which is new, Vendegna instructs.

Starting in January, when cardiologists add bi-ventricular pacing capability to existing pacemakers and defibrillators, coders can use 33224 (Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator [including revision of pocket, removal, insertion and/or replacement of generator]), a new code specifically for such pacemaker system overhauls.

New text inserted in the CPT 2003 pacemaker section states that in certain circumstances, "an additional electrode may be required to achieve pacing of the left ventricle (bi-ventricular pacing)." In these situations, "transvenous (cardiac vein) placement of the electrode should be separately reported using code 33224 or 33225," according to CPT 2003.

The AMA developed 33224 specifically for a device that upgrades an existing pacemaker so that it can achieve bi-ventricular pacing, explains Jim Collins, CHCC, CPC, president of Compliant MD Inc. in Matthews, N.C., and compliance officer of a 26-physician cardiology practice. New bi-ventricular devices are available now, which could mean that fewer cardiologists will need to attach adapters to existing pacemakers, he notes.

If you are upgrading a pacemaker by adding cardiac venous system electrodes (otherwise known as coronary sinus leads), you would bill 33224 as a stand-alone code, Vendegna advises. She stresses that 33224 includes the revision of the pocket and the removal and replacement of the pacemaker generator if these procedures are part of the system upgrade.

In the past, you could bill separately for removing the generator, but this procedure is now part of 33224, Vendegna notes. Coding experts predict that CMS will elevate the relative value units for 33224 to reflect the incorporation of the generator removal.

CPT 2003 also rolls out +33225 (Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator [including upgrade to dual chamber system] [list separately in addition to code for primary procedure]), an add-on code for electrode insertion in brand new pacing systems.

In other words, if the cardiologist is putting in a totally new system, regardless of whether its a pacemaker or a defibrillator, you should use the base code for the device and add 33225, which is the new coronary sinus lead code, Vendegna explains.

According to parenthetical information accompanying the 33225 description, you should use 33225 with the following primary pacemaker procedure codes: 33206-33208, 33212-33214, 33216-33217, 33222, 33233-33235, 33240 and 33249.

The AMA likely will delete 33206 (Insertion or replacement of permanent pacemaker with transvenous electrode[s]; atrial) from the list of codes that 33225 can be added to, Collins observes. Code 33206 involves implanting a single chamber pacemaker with an atrial lead. If you add a bi-ventricular lead to it, you wont have bi-ventricular pacing because youre pacing the right atrium of the heart and the left ventricle but not both ventricles, he explains. Moreover, you should use 71090 (Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation) to report the fluoroscopic guidance used during pacemaker and cardioverter defibrillator insertion.

A switch in phrases in 93620 (Comprehensive electro-physiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording) puts new emphasis on electrode insertion and repositioning for arrhythmia induction. In spite of this, its the same code, and you would use it the same way, Vendegna confirms.

CPT 2003 also presents cardiologists with two new codes for reporting septal defect repair, which includes inserting a coil device to occlude a hole in the heart:

93580 Percutaneous transcatheter closure of congenital interatrial communication (i.e., fontan fenestration,atrial septal defect) with implant

93581 Percutaneous transcatheter closure of a congenital ventricular septal defect with implant.

A parenthetical note appended to each of these new codes states that septal repair procedures include right heart catheterization and contrast dye injection, so you should not report 93501, 93529-93533, 93539, 93543 and 93555 with 93580 and 93581.

Note: The January 2003 Cardiology Coding Alert will include a special 8-page supplement on coding bi-ventricular procedures.

The American College of Cardiology (ACC) will have copies of its ACC Guide to CPT 2003 available in mid-January. To order the Guide, call 800-253-4636, ext. 694.