Outpatient Facility Coding Alert

Can you code when removing an old component?

You have a chart documenting where the surgeon replaced a patient’s dual pacemaker for end of life and also replaced a malfunctioning atrial lead. It might not be a situation you see every day, but read on for tips on reporting the situation.

Starting point: The American Medical Association (AMA) says it’s OK to bill for both stages of the procedure separately, according to consultant Jim Collins, CHCC, CPC, ACS-CA, President, The Cardiology Coalition in Matthews, N.C. Collins wrote to the AMA as a consulting editor with The Coding Institute and asked about this situation, and received a response in writing.

When a pulse generator reaches its “end of life” you can code with 33212 (Insertion of pacemaker pulse generator only; with existing single lead) or 33213 (Insertion of pacemaker pulse generator only; with existing dual leads). The difference between 33212 and 33213 is whether there are one or two leads to reconnect to the pulse generator and whether there are one or two leads for which pacing and sensing parameters must be tested.

You can bill for the removal of the existing pulse generator using CPT® 33233 (Removal of permanent pacemaker pulse generator only). For old atrial electrode, you can separately report 33235 (Removal of transvenous pacemaker electrode[s]; dual lead system). Finally, if you replace both the generator and the electrode, use code 33206 (Insertion of a new or replacement of permanent pacemaker with transvenous electrode[s]; atrial). Many a times the removal would be undertaken for an infectious situation. When infection is present it is important that the lead be removed.

“When practices take out old system components ... they should bill for what they take out in addition to billing for what they put in,” Collins says.

Additional information: Other tips related to coding the scenario include:

• Use 33206 when the services involve insertion or replacement of a permanent pacemaker with transvenous electrodes in an atrium.
• Use 33207 when the services involve insertion or replacement of a permanent pacemaker with transvenous electrodes in a ventricle.
• Use 33208 when the services involve insertion or replacement of a permanent pacemaker with transvenous electrodes in both the right atrium and right ventricle.

Know the Exception to the Rule

The only exception to this rule is if the physician upgrades from a single-chamber device to a dual-chamber device. In that case, use 33214 (Upgrade of implanted pacemaker system, conversion of single-chamber system to dualchamber system...). The expanded descriptor for that code clarifies that this includes the removal of a previously placed pulse generator, as well as testing of the existing lead, insertion of the new lead, and insertion of the new generator.

In practice, you may find it difficult to obtain payment for both removal of old components and the placement of new ones, and may often face denials for complex pacemaker replacement procedures.

Typically, you would see lot of reviews on these bills. However, you may obtain payment on appeal, but it involves a lot more work. To avoid this, you should make sure the physician documents in detail the reason for removal of the old pacemaker and lead. Document whether it was due to a pocket infection or “end of life,” as the codes could vary based on the reason of removal.