Cardiology Coding Alert

Pull out the red pen to mark this LV-lead correction in your manual.

Certain biventricular upgrade cases have been frustrating coders, but there's good news.

Finding the proper code combination is much simpler now that the AMA has published an official correction to the primary codes you may report with +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 and pocket revision] [List separately in addition to code for primary procedure]).

Add Gen Change Codes to Primary Options

The corrections document for AMA's CPT® 2012 manual revises the parenthetical instruction following +33225. The revision adds four codes to the list of possible primary codes for +33225:

• 33228, Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system
• 33229, ... multiple lead system
• 33263, Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; dual lead system
• 33264, ... multiple lead system.

Remember that because +33225 is an add-on code, you must report it in addition to a primary code. You may never report +33225 without an appropriate primary code.

Review These Upgrade Cases for Denials

The addition of 33228, 33229, 33262, and 33264 to the list of primary codes resolves an issue many coders have confronted since the codes became effective in January.

Affected cases are upgrades from a single- or dual-lead pacemaker or implantable cardioverter-defibrillator system to a biventricular (BiV) system. Specifically, the cases involve the physician placing the left ventricle lead (+33225), changing the pulse generator, and connecting previously placed lead(s) to the new battery.

For example, suppose the physician removes an existing single pacer generator, inserts a BiV pacer generator, connects the existing right ventricle (RV) lead, and implants and connects a new left ventricle (LV) lead, says Carol Wright, CPC, of Elmira, NY. The 2012 coding guidelines originally published didn't offer clear guidance on how to code this scenario.

The problem: The logical assumption is that you should report +33225 with the applicable generator change code when a case involves LV lead placement (+33225) and generator change (such as 33228, 33229, 33263, or 33264). But CPT® did not list the new generator change codes as acceptable primary codes for +33225.

Result: When practices attempted to report the generator change codes along with +33225, they received denials, says Terry A. Fletcher, BS, CPC, CCS-P, CCS, CEMC, CCC, CMSCS, CMC, of Laguna Beach, Calif.-based Terry Fletcher Consulting.

Practices were left trying to find another coding option. Some coders wondered if they could code the LV lead placement (+33225), a new system insertion (such as 33206-33208, Insertion of new or replacement of permanent pacemaker with transvenous electrode[s] ...), and possibly battery removal (such as 33233, Removal of permanent pacemaker pulse generator only). "This is technically incorrect from a coding perspective because there was an LV lead added, but no RA or RV lead changed," Fletcher says. The new system codes require lead insertion or replacement, so 33206-33208 would not be correct here.

Before the correction was published, Fletcher and other experts recommended using the new battery change codes in addition to +33225 and being "ready with an appeal explaining your position."

Put the +33225 Correction to Work for You

With the publication of the errata, you know that you may report the pulse generator removal and replacement as a primary code and also report +33225 for the placement of the new LV lead. Experts advise choosing the pulse generator replacement code based on the device the patient leaves the encounter with. So if the patient goes from a double-lead system to a multiple-lead system, the recommended pulse generator code would be for a multiple-lead system (33229 or 33264).

Documentation tip: You'll see generator changes with BiV upgrades to allow a Y-adaptor for the extra lead, Fletcher says. Some physicians may not think to include the generator change in the documentation because they consider it a given. Work with providers to ensure the generator change is documented when performed to support coding.

Resource: The correction document is available online at www.ama-assn.org/resources/doc/cpt/cpt-corrections.pdf. Note that it makes one other change to the parenthetical note with +33225, deleting 33222 (Revision or relocation of skin pocket for pacemaker) from the list of primary codes.