Part B Insider (Multispecialty) Coding Alert

Bill 33233, 33235 and 33206 for removal and replacement

If a physician replaces both a generator and a lead on a pacemaker, how can you code this procedure? Can you use multiple codes to capture the removal and replacement, or just one code for everything?

Here's the situation: The generator on a patient's dual pacemaker needs to be replaced for end of life. And then the physician also replaces a malfunctioning atrial lead. Some coders believe that you can't bill for removing the old components as well as placing the new ones.

But in fact the American Medical Association has said that it's OK to bill for both stages of the procedure separately, according to consultant Jim Collins with Compliant MD Inc. 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.

The AMA said you can bill for the removal of the existing pulse generator using CPT 33233 (Removal of permanent pacemaker pulse generator). And you can report the removal of the old atrial electrode separately using 33235 (Removal of transvenous pacemaker elec-trode[s]; dual lead system). Finally, if you replace both the generator and the electrode, use code 33206 (Insertion or replacement of permanent pacemaker with transvenous electrode[s]; atrial).

But you can also bill separately for the radiological supervision and interpretation portion of this procedure, the AMA told Collins. Use 71090 (Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation) to cover this part.

"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.

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 dual-chamber 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, it can be very difficult to obtain payment for both removal of old components and the placement of new ones, says coder Jennifer Kelchen in Cedar Rapids, Iowa. Her carrier, Noridian, often denies claims for complex pacemaker replacement procedures.

"We should be able to bill for the removal and the replacement in those situations, but typically I see a lot of reviews on those," she says. Usually, she obtains payment on appeal, but it involves a lot more work. A key element: making sure the physician documents in detail why the old pacemaker and lead had to be removed, due to either a pocket infection or "end of life."