Cardiology Coding Alert

Question: The cardiologist implanted a pacemaker in a patient on Sept. 15. The patient returned to the hospital several weeks later with "oozing from the pocket." The cardiologist sent the patient to the cath lab for a hematoma evacuation. The cardiologist then made a second incision over the top of the first incision, performed a hematoma evacuation, flushed and cleaned out the original pocket, put the device back, and closed the pocket. The cardiologist documented the procedure as complex. Can we code a 33222 for this?

California Subscriber

Answer: No. This particular situation is pocket revision, not pocket relocation, so you would not report 33222 (Relocation of skin pocket for pacemaker).

Background info: A pacemaker system with leads is made up of a pulse generator that contains electronics, a battery, and one or more leads. A lead contains one or more electrodes, conductor wires, insulation, and a fixation mechanism. The cardiologist places the pulse generator in a "pocket" located under the skin - in an area beneath the collarbone or above the abdominal muscles just below the ribcage. The cardiologist either inserts the leads through the vein or places the leads on the surface of the heart.

For a pocket revision, the cardiologist debrides the scar tissue or infection, and places the generator back in its original pocket.

The CPT^® manual instructs you to look to the following codes when the skin pocket revision includes incision and drainage of a hematoma or complex wound infection:

• 10140, Incision and drainage of hematoma, seroma or fluid collection
• 10180, Incision and drainage, complex, postop­erative wound infection 
• 11042-11047, Debridement ...

Because the cardiologist performed an incision and drained a postoperative wound infection in a procedure you described as complex, 10180 would be an appropriate code choice for you.

Don't forget modifier 78: Since all of the pacemaker implantation codes 33206-33208 (Insertion of new or replacement of permanent pacemaker with transvenous electrodes ...) have 90-day global periods, you would append modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) to 10180 because you would bill a return to the cath lab the same as a return to the operating room.

In contrast to a revision, for a pocket relocation the cardiologist opens the existing pocket, incises and drains the hematoma, closes the pocket, and creates a new pocket for the generator. In that case, you would report 33222, says CPT^®.