Cardiology Coding Alert

Question: A patient who had a pacemaker implanted on Sept. 15 returns to the hospital with "oozing from pocket" on Oct. 7. He is taken to the catheterization lab for hematoma evacuation. A second incision is made over the top of the first one, hematoma evacuation is performed, the pocket is flushed and cleaned, the device is put back, and the pocket is closed. Is this a pocket revision? How should we code this?

Pennsylvania Subscriber
Answer: This is a good example of how "cardiology tunnel vision" that is, the tendency to research cardiology-related codes, e.g., codes in the "Pacemaker or Pacing Cardioverter-Defibrillator" section of the CPT manual, without researching other codes can inhibit the selection of a billable code.
 
The procedure described is not a true pocket revision 33222 (revision or relocation of skin pocket for pacemaker) which involves physically moving the pocket. 

Because the cardiologist has performed an incision and drainage of a postoperative wound infection, 10180 (incision and drainage, complex, postoperative wound infection) would apply.
 
Because all the pacemaker implantation codes 33206 (insertion or replacement of permanent pacemaker with transvenous electrode[s]; atrial), 33207                   (... ventricular) and 33208 (... atrial and ventricular) have 90-day global periods, append modifier -78 (return to the operating room for a related procedure during the postoperative period) to 10180 (a return to the catheterization lab is considered a return to the operating room). 
 
Note: Medicare considers complications that result from a surgical procedure part of the global surgical package and permits separate payment for treating complications only if the patient returns to the operating room. However, CPT's newly introduced definition of a surgical package (found in the "Surgery Guidelines" preceding the "Surgery" section of CPT 2002) does not include complications, and many private payers may not consider the treatment of a complication to be a related procedure. In such cases, the carrier may require modifier -79 (unrelated procedure or service by the same physician during the postoperative period) or no modifier at all for the incision and drainage.