Cardiology Coding Alert

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

California Subscriber

Answer: The procedure you describe is not a true pocket revision -- 33222 (Revision or relocation of skin pocket for pacemaker) -- which typically involves physically moving the generator to a new pocket.

Because the cardiologist performed an incision and drained a postoperative wound infection, you could report 10140 (Incision and drainage of hematoma, seroma or fluid collection) or 10180 (Incision and drainage, complex, postoperative wound infection). You'll pick the correct code based on your documentation: 10140 for simple procedures, 10180 for complex ones.

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. You should append modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) to 10180 because Medicare considers a return to the catheterization lab the same as a return to the operating room.

Medicare includes surgical procedure complications in the global surgical package. When the complication requires a return to the operating room, Medicare allows separate payment.