20 Jul 2017

Pacemaker coding guidelines

                  Temporary pacemaker – worn externally
                   Permanent pacemaker – Placed into the chest (Subcutaneous)

    A pacemaker system consists of, 

            -     A pulse generator (Battery)

            -     Leads (Electrodes)

Location of Pulse generators (Subcutaneous pocket)
           1.    Below clavicle

           2.    Below the ribcage just above the abdomen muscles.

Leads may be inserted through
           1.    Transvenous (via the vein)

           2.    Epicardial (Placed on the surface of the heart)
                Note: Thoracotomy is required for insertion of Epicardial leads. 

A single chamber pacemaker

Pulse generator with a single lead and one electrode inserted in either atrium or ventricle

Dual-chamber pacemaker

Pulse generator with two leads (one lead in the right atrium and one lead in the right ventricle) attached with two electrodes.

Note: In certain circumstances, an additional lead may be required for left ventricle should be separately reported based on its placement  
            A.  Transvenous placement of the lead should be separately reported using CPT 33224 / 33225.

             B.    Epicardial placement of the lead should be separately reported using CPT 33202 / 33203

Leadless cardiac pacemaker
          -    Pulse generator with battery
          -    Electrode

Implantable Defibrillator:
         1.    ICD – Transvenous implantable pacing cardioverter-defibrillator
         2.    S-ICD – Subcutaneous implantable defibrillator

The pulse generator location (Subcutaneous)
             1.    Infraclavicular
             2.    Axillary

             3.    Abdominal pocket

Note: Removal of pulse generator requires an opening of the subcutaneous pocket and disconnection of the pulse generator from its electrodes.

The electrodes (leads) of an implantable defibrillator may be positioned within the atrial and/or ventricular chamber of the heart

              A.  Transvenous (via the vein)
              B.    Epicardial (Placed on the surface of the heart)
              C.  Subcutaneous (Positioned under the skin overlying the heart)

·        Electrode placement on the Epicardial surface of the heart requires a thoracotomy or thoracoscopic placement of the leads. Would be separately reported using 33202 / 33203

·        Electrode (lead) of the S-ICD is tunnelled under the skin to the left parasternal margin,  hence the Subcutaneous placement of electrode may be reported using 33270 or 33271  

·        For additional electrode (left ventricle / Bi-ventricular pacing), Transvenous placement of the electrode may be separately reported using 33224 or 33225

        Coding Guidelines:

If a battery of a pacemaker or defibrillator is changed = It is a pulse generator changed.

         Removal of only the pulse generator of pacemaker or defibrillator (33233 or 33241)

                 Insertion / Replaced only the pulse generator without leads replaced report appropriate code (33227, 33228, 33229 & 33262, 33263, 33264) based on the number of existing leads. Don’t report removal of pulse generator codes (33233 or 33241) separately.

                 Insertion of the new pulse generator when existing leads are already in place and no prior pulse generator is removed – (33212, 33213, 33221, 33230, 33231, 33240)

                 Insertion of a pulse generator along with insertion or replacement of one or more right atrial and/or right ventricular or subcutaneous leads33206, 33207, 33208 for pacemaker  and 33249 for ICD or 33270 for S-ICD

                 For reporting the system insertion or replacement codes, removal of a pulse generator (33233 or 33241) may be reported separately when performed.  In addition extraction of leads 33234, 33235 or 33244 for Transvenous or 33272 for subcutaneous may be reported separately when performed.  

        For removal of the Transvenous electrode by Transvenous extraction (33234, 33235 or 33244) 

        For removal of the Transvenous electrode using Thoracotomy (33238 or 33243)

        For removal of subcutaneous implantable defibrillator electrode (33272) 

        For removal of the leadless pacemaker

Use 33212, 33213, 3322133230, 33231, 33240 as appropriate in addition to the thoracotomy or endoscopic Epicardial lead placement codes (33202 or 33203) to report the insertion of the generator if done by the same physician during the same session.

                Up-gradation of the pacemaker from single to a dual system includes removal of a pulse generator, replacement of new pulse generator and insertion of a new lead.  CPT 33214

                Revision of a skin pocket is included in 33206-33249, 33262, 33263, 33264, 33270, 33271, 33272, and 33273. Note: If revision of skin pocket involves Incision and drainage of hematoma or complex wound infection, code appropriate codes (10140, 10180, 11042, 11043, 11044, 11045, 11046, and 11047)

                Relocation of a skin pocket for a pacemaker (33222) or ICD 33223

                If skin pocket relocation is performed as part of the replacement of generator – skin pocket relocation is reported separately.  Note: Skin pocket relocation codes include all the work associated with the initial pocket (Opening the pocket, I&D of hematoma or abscess, and closure)

                Repositioning of a pacemaker electrode, ICD or left ventricular pacing electrode is reported using 33215, 33226 or 33273

                Don’t report device evaluation codes (93260, 93261, 93279-93299) for pacemaker in conjunction with pulse generator and lead insertion or revision codes (33206-33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273).

                Don’t report device evaluation for the leadless pacemaker – 0389T, 0390T, 0391T in conjunction with insertion and removal codes 0387T, 0388T.

               DFT (Defibrillator threshold testing) during Transvenous implantable defibrillator insertion or replacement may be separately reported using 93640, 93641

               Don’t code DFT during S-ICD system insertion.

               DFT testing in follow up or at the time of replacement of Transvenous/subcutaneous implantable defibrillator may be separately reported using 93642 / 93644  

               Radiological supervision and interpretation related to the pacemaker or implantable defibrillator procedure is included in 33206 – 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, 0387T, 0388T.

         Note: Fluoroscopic guidance for diagnostic lead evaluation without lead insertion, replacement or revision procedures – use 76000

        Test your Knowledge:

            A. Cardiovascular CPC Sample Quiz