Cardiology Coding Alert

Get ready to code more internal cardioverter-defibrillator (ICD) implants in the coming months. Recently approved coverage criteria for ICD implants could bring your cardiology practice an increase in these procedures, and this means you'll need to be up-to-speed on ICD implant billing basics .
 
(For more on the new coverage criteria, see "Understand MADIT II Coverage" below.) 

What Is an ICD?

An ICD is a device with leads that the cardiologist implants in the heart muscle and connects to a generator that monitors the heart's rhythm. The generator monitors for a "too fast" heart rate and sends a shock intended to bring the patient's heart back to a normal sinus rhythm. 

5 Tips for Coding the Implant

1. Use the same code for single- and dual-chamber systems. Don't worry about distinguishing between single- and dual-chamber devices when the cardiologist implants a new ICD system. This is because implant procedure code 33249 (Insertion or repositioning of electrode lead[s] for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator) is for either single- or dual-chamber devices. So use this code for either system.
 
You should keep track of whether the physician implanted single- or dual-chamber devices, however, for auditing purposes, says Brian Outland, coding and reimbursement specialist with North American Society of Pacing and Electrophysiology (NASPE).
 
Although the CPT code selection is the same whether the cardiologist uses a single or dual cardioverter-defibrillator, we routinely encourage physicians to document the details of the procedure they perform accordingly, says Cynthia Swanson, RN, CPC, a cardiology coding specialist with Seim, Johnson, Sestak and Quist LLP in Omaha, Neb.
 
2. Report fluoro with 71090. Typically, you will report fluoroscopy at the time of ICD implant the same way you report fluoroscopy for pacemaker implants - with 71090 (Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation).  Although 71090's definition mentions only pacemakers, the AMA confirms that it is the appropriate code to report for ICD implants as well, Outland and Swanson say.    
 
Indeed, the AMA's CPT Assistant (August 2002) states that "CPT code 71090 ... is intended to be used with pacemakers or cardioverter-defibrillators," Swanson says.
 
Fluoro tip: Your physician will likely use fluoroscopy to visualize the leads' advancement into the appropriate location but won't always note this in the operative report. If you find that your physicians do not clearly document fluoroscopy, make sure you inform them that this is a separately billable/reimbursable service, but only if their operative reports support it. 
 
"Code 71090 has a global, technical and professional fee allowance," Swanson says. "If the physician is billing for the professional component (modifier -26), documentation must be available to support the supervision and interpretation of the test."
 
3. Look for EP test details. Frequently, you will need to bill for an electrophysiologic (EP) test of the ICD system during the implant. Because ICDs are responsible for saving a patient's life when the heart goes into life-threatening abnormal rhythm, physicians need to confirm that they implanted and programmed the system appropriately before sending the patient home. Physicians induce an arrhythmia to confirm that the ICD system detects and terminates the rhythm, says Colleen McKee, CPC, senior coding consultant and team leader with Knoxville Cardiovascular Group in Knoxville, Tenn. But not all ICD implant procedures also have an EP study, because some patients are too frail to undergo the testing during the implant.       
  
4. Use 93641 for ICD lead and generator checks. When the physician tests the system during an implant, 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), McKee says.
 
Keep in mind that 93641 involves testing both the leads and generator, whereas 93640 (Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads ...) is for lead testing only. So you'll need to look carefully at the notes to determine whether the physician tested both leads and generator (93641) or the leads only (93640), coding experts say.
 
5. Don't confuse EP device tests with comprehensive studies. Remember that the EP evaluation during the implant is not synonymous with the comprehensive EP studies reflected by 93619 and 93620, coding experts say. With these comprehensive EP studies, the physician places multiple electrodes in the heart chambers to pace the right atrium and ventricle and to record data from the right atrium, bundle of His, and right ventricle. With the EP evaluation of an ICD device, however, the physician induces an arrhythmia and confirms that the device is properly functioning.   
      
Note: See "Look at the Whole Picture When Coding Comprehensive EP Studies" in the April 2003 Cardiology Coding Alert for more on comprehensive EP studies.