Cardiology Coding Alert

The cardiologist's notes state that he engaged the coronary sinus with a deflectable quadripolar catheter under continuous fluoroscopic guidance. He advanced the catheter into the mid-sinus region, removed the catheter, and flushed the sheath. He advanced a balloon-tip catheter into the sheath and took occlusive venograms of the coronary sinus.

The cardiologist inserted a left-ventricular pacing lead and BMW guide wire into the sheath and found a stable position for the pacing wire in an anterolateral branch. After placing the right ventricular and right atrial leads and connecting the leads to the generator, he inserted the generator into a subcutaneous pocket. He induced ventricular fibrillation on two separate occasions. Both were successfully sensed and terminated.

Answer: This documentation is representative of a typical biventricular ICD implantation. You should code everything as you would in the absence of left ventricular pacing, and then add on the new left ventricular electrode code +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]).

You should report the implantation of the ICD with 33249 (Insertion or repositioning of electrode lead[s] for single- or dual-chamber pacing cardioverter-defibrillator and insertion of pulse generator) and 71090-26 (Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation; professional component) for the fluoroscopic guidance required during lead insertion.

Report 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) for the electro-physiologic evaluation of the leads and generator.