Cardiology Coding Alert

NCCI version 9.2 edits, effective July 1, establish a one-day wait period for repositioning pacemaker and defibrillator leads - a wait that many thought was completely eliminated in CPT 2003. 

Last year, coders had to wait 15 days or more to bill for lead repositioning. The repositioning codes new to CPT 2003, 33215 (Repositioning of previously implanted transvenous pacemaker or pacing cardioverter-defibrillator [right atrial or right ventricular] electrode) for right atrial or right ventricular electrode lead repositioning and 33226 for left ventricular lead repositioning, do not have any "wait period" included in their definitions. 

So, where does the one-day wait period come from?  The version 9.2 edits list 33215 as "mutually exclusive" (not billable with) 33206, 33207, 33208, 33214, 33216, 33217, 33234, 33235 and 33249 - the codes for insertion of pacing and/or defibrillation systems and the electrode insertion and removal codes. Put simply, the edits indicate that you should not bill 33215 when the cardiologist repositions a right atrial or right ventricular electrode lead on the same day as lead or generator implantation, coding experts say.

The edits list 33226, the new coronary sinus lead repositioning code, as mutually exclusive of the codes for insertion of pacing and/or defibrillation systems and the electrode insertion and removal (see list above), as well as 33211 for temporary dual-chamber pacemaker insertion, 33212 for insertion or replacement of a single-chamber pacemaker pulse generator, 33213 for dual-chamber pulse generator insertion or replacement, and electrode repair codes 33218 and 33220.  These edits establish a one-day wait period, as well, coding specialists say.

The edits for codes 33215 and 33226 have a "0" modifier indicator, which means that you cannot append a modifier, such as modifier -59 (Distinct procedural service) to override the edit. 

The "0" indicator for these edits raises questions, coders say. There are procedures in CPT's surgical section that you may append modifier -78 to and bill when a patient returns to the operating room for a complication, regardless of the date of service. So why should pacer or lead repositioning guidelines be different? asks Nancy Reading, RN, BS, CPC, president elect of the American Association of Professional Coders (AAPC) and staff educator with University Medical Billing at the University of Utah.

"If the lead is in a bad position and is not capturing, then a patient in third-degree heart block will be beyond the benefits of a replacement pacer or cardioverter defibrillator if they are to wait one day," Reading says. 

Left Ventricular Leads Have Selective Components

Codes 33224 and 33225 for left ventricular (LV) lead implantation now include as components the codes for venous selective catheter placement, first-order vessel (36011) and second-order vessel (36012), as well as the code for sinus or jugular venography (75860). These new edits concur with guidance from the AMA indicating that you should not report coronary sinus venography in addition to LV lead placement.

The new edits also bundle 33224, for the addition of an LV lead to an already-implanted generator, into 33212 and 33213, the codes for insertion/replacement of a pacemaker generator only.

Cardiac Rehab ECG Services Include Stress Tests

A group of new edits may also change the way you report stress tests with cardiac rehabilitation services.

In particular, NCCI 9.2 lists outpatient cardiac rehab physician services, with and without electrocardiogram (ECG) monitoring (93797 and 93798), with mutually exclusive codes 93015 for the stress test, 93017 for stress test tracing only, 93018 for stress test interpretation and report only, and 93025 for T-wave alternans assessments. Each of these edits are new, with the exception of the edit listing stress test code 93015 as mutually exclusive of 93798, which was in place prior to NCCI 9.2.

Each of these edits has a "1" modifier indicator, which means that NCCI-specific modifiers will allow you to report these services together when appropriate. For instance, a patient might have ECG changes during stress testing, says Judy Allen, CPC, a peripheral interventional coding specialist and compliance officer for Birmingham Radiology Group in Birmingham, Ala.

In this situation, you could append modifier -59 to the appropriate stress test code, but the physician would have to document this really well, Allen adds.
 
PET Myocardial Imaging Bundles Needle Codes

If your practice offers positron emission tomography (PET) imaging of the myocardium, take note that the new edits bundle 36000* (Introduction of needle or intracatheter, vein) for needle insertion into the vein, 36140 (... extremity artery), and 90780 (Intravenous infusion for therapy/diagnosis ...) into the PET imaging code 78459 (Myocardial imaging, positron emission tomography [PET], metabolic evaluation). So, you would not report these procedures separately when reporting PET imaging.

Edits Delete CPR Bundling With Pacer Services

Not all of the cardiology edits were additions. NCCI 9.2 removes eight edits that bundled cardiopulmonary resuscitation (CPR) (92950, Cardiopulmonary resuscitation [e.g., in cardiac arrest]) into a handful of pacemaker/defibrillator-related services. 

Because physicians rarely provide CPR to patients undergoing pacemaker/defibrillator implantation or lead repositioning services (33216, 33240, 33241, 33243, 33244, 33245, 33246 and 33249), these edit deletions should not have a significant impact on billing or revenue. If you can identify patients who have had CPR performed during one of these procedures, however, you can go back and file a new claim for it. This is because the edit deletions are retroactive to the implementation date (Oct. 1, 1998.)