Cardiology Coding Alert

Tip: Forgetting modifier QR could drop your claim into limbo land

Several implantable cardio-defibrillator manufacturers have recently recalled a few models, so you may be looking at a stream of ICD replacement procedures hitting your desk any day now. Prepare for this influx by reading this step-by-step advice that will ensure your success with every claim.

Before jumping into the procedural coding for an ICD replacement, you need to be sure you have identified the correct diagnosis code. In a recall situation, you should report 996.04 (Mechanical failure of automatic implantable cardiac defibrillator) to support the removal of the ICD.

For the generator replacement, you should use the diagnosis originally cited for the ICD (such as 427.41, Cardiac dysrhythmias; ventricular fibrillation and flutter; ventricular fibrillation), says Sandy Fuller, CPC, a compliance officer at Cardiovascular Associates of East Texas in Athens. Use These Codes in Lieu of a Single CPT Replacing an ICD doesn't require a slew of CPT codes. Narrow down what you should report to the following codes:
  33240 - Insertion of single- or dual-chamber pacing cardioverter-defibrillator pulse generator
  33241 - Subcutaneous removal of single- or dual-chamber pacing cardioverter-defibrillator pulse generator
  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. In other words, you'll code the generator removal with 33241 and generator replacement with 33240, Fuller says. 

And if the doctor performs an EP evaluation of the system (including arrhythmia induction), make sure to include 93641, says Patricia Gajewski, CPC, a full-time coder at Consultants in Cardiovascular Disease Inc. in Erie, Pa.

Don't miss: If you're reporting these codes together for a non-Medicare patient, you'll most likely need to append modifier 51 (Multiple procedures) to 33241 (removal of ICD only) and also append modifier 26 (Professional component). For Medicare patient, you'll still include modifier 26 on 33241.

If your cardiologist inserted the ICD for a non-arrhythmia diagnosis (such as, for MADIT II or SCD-HeFT patients) and the patient has Medicare, you should be sure to add modifier QR, Fuller says. Medicare patients who receive an ICD or replacement ICD as a primary prevention of sudden cardiac death must be enrolled in a data collection system. Otherwise, Medicare may not cover the procedure. Adding modifier QR to your claim will signify the patient's enrollment in the registry.
Keep in mind: If the cardiologist upgrades a dual- chamber ICD to a biventricular ICD, you should use the same codes with the same modifiers but add +33225 (Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of [...]