Cardiology Coding Alert

Question: Which codes apply to this service?

1) Venography of left subclavian

2) Venogram of right subclavian vein

3) Placement of Medtronic LV lead

4) Removal of Medtronic Impulse dual chamber pacemaker

5) Implantation of CRT-P BIV pacer

6) Venoplasty of totally occluded right subclavian vein

7) Fluoroscopy

Codify Member

Answer: This appears to be an upgrade of a dual-chamber pacemaker to a cardiac resynchronization therapy pacemaker (CRT-P) system.

For the addition of the left ventricular (LV) lead, report +33225 (Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator [e.g., for upgrade to dual chamber system] [List separately in addition to code for primary procedure]).

The appropriate primary code for +33225 in this case is 33229 (Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system). This code covers the removal of the dual-chamber generator and the insertion of the new biventricular-capable generator.

You should not report fluoroscopy for the upgrade service separately. “Radiological supervision and interpretation related to the pacemaker or pacing cardioverter-defibrillator procedure is included in 33206-33249,” state CPT^® guidelines.

For the venoplasty, look at 35476 (Transluminal balloon angioplasty, percutaneous; venous) and 75978-26 (Transluminal balloon angioplasty, venous [e.g., subclavian stenosis], radiological supervision and interpretation; Professional component).

Before deciding whether to code the venograms, you need to review the documentation. Venography performed to guide the pacer-related services or “facilitate entry” is not diagnostic, and you shouldn’t report it separately, according to CPT^® Assistant (May 2008). But for a truly diagnostic study that results in venoplasty, consider 75820-26 (Venography, extremity, unilateral, radiological supervision and interpretation). Bilateral diagnostic venography is coded using 75822-26 (Venography, extremity, bilateral, radiological supervision and interpretation). There also may be medical necessity for extremity venography before placing a new lead in a patient with existing lead(s), not to determine vein patency or for roadmapping, but to determine an adequate venous channel for the new lead(s) prior to placement. The physician’s documentation should appropriately explain why the venography was medically necessary for the specific patient.