Vol. 14 •Issue 15 • Page 14
Permanent Pacemakers with Transvenous Electrodes Present CPT Coding Challenges
(Editor’s note: The previous column, “Brush Up on Integumentary System CPT Coding, Part 1” ran in the June 21 issue. The second part of this article, discussing more details about integumentary coding, will appear in the August 16 issue.)
The CPT coding of permanent pacemakers with transvenous electrodes present a challenge to the coding community simply because of the many procedures involved. There are initial insertions, replacements of all the components, replacements of some of the components, repositioning, repair, upgrades, etc. Also, one must keep in mind the type of pacemaker, single or dual chamber with the corresponding placement of the leads, atrial and/or ventricular. There is also the possibility of the requirement of another electrode being placed in the left ventricle for the purpose of biventricular pacing. For the purpose of this article, we will address only those procedures in which the electrodes are inserted through the vein, transvenous, and not those where the electrodes are placed on the surface of the heart, epicardial. The former may be done on an outpatient basis, but the later is an inpatient procedure.
For a list of the available codes and their descriptions, visit the online version of this article at www.advanceweb.com/him.
Today’s pacemakers can be programmed in literally millions of possible combinations. Their main purpose is to keep the electrical system from going too slow and thereby prevent the problems associated with slow heart rhythms (passing out, congestive heart failure and others, including death). Pacemakers are necessary because, while there are many medications that prevent the heart from going too fast, there are only a handful that make it go faster. Those that speed the heart rate are poorly tolerated and very often associated with serious side effects. Pacemakers have become a reliable means of helping people live longer and improve their lifestyles despite having a slow heart rhythm. Newer types of pacemakers can correct some types of rapid heart rhythms as well.
Patients require pacemakers for many different reasons. Most pacemakers are placed to prevent the heart from going too slow. Most often, this occurs because there is no cell in the heart that will beat fast enough to maintain proper function, or because there is a “block” somewhere in the electrical pathway that doesn’t allow the electrical activity to spread to all of the necessary portions of the heart muscle. The underlying cause of this may be scar tissue, most frequently from previous heart attacks. Sometimes it is simply caused by “aging” of the conduction system.
Single lead pacemakers are used primarily in four situations:
1. When the only problem is with the formation of the initial impulse in the atrium, simply placing a lead in the right atrium will “start things off” when it’s needed, and the electrical impulse will then continue normally through the rest of the atrium, the AV node and the ventricles.
2. When the patient is in chronic atrial fibrillation and the ventricle rhythm is quite irregular, only a single lead is placed in the ventricle (because the fibrillating atrium cannot be paced).
3. When the problem with a slow rate occurs only occasionally and for relatively brief periods of time, a single lead in the ventricle may be all that is utilized to provide brief help at those times.
4. A special lead that can sense in both chambers and pace only in the ventricle is also useful in some situations.
“Dual chamber” devices (with one lead in the right atrium and one in the right ventricle) are desirable in many situa- tions. Such devices keep the upper and lower chambers contracting in their pro-per sequence.
A pacemaker system includes a pulse generator containing electronics and a battery, and one or more electrodes (leads). Pulse generators are placed in a subcutaneous pocket created in either a subclavicular site or underneath the abdominal muscles just below the ribcage. Electrodes may be inserted through a vein (transvenous) or they may be placed on the surface of the heart (epicardial). The epicardial location of electrodes requires a thoracotomy for electrode insertion. Again, for the purposes of this article, issues involving permanent pacemakers with epicardial electrodes will not be addressed because they are inpatient procedures.
Single chamber devices may pace in either the atrium or ventricle, although it is much more common for these devices to be placed in the ventricle. Dual chamber systems involve the insertion of electrodes into both the atrium and the ventricle, and the use of a pulse generator capable of pacing and sensing both the atrium and the ventricle.
In some patients with supraventricular tachycardia, an antitachycardia pacemaker may be chosen. These devices usually provide a combination of treatments, and include the following:
1. Overdrive pacing for termination of the tachycardia. (The pacemaker terminates the patient’s tachycardia by overriding the patient’s abnormal rhythm.)
2. Critically timed premature beats to terminate tachycardia. (The pacemaker terminates the patient’s tachycardia by providing beats that slow the electrical conduction); and
3. Backup bradycardia pacing. (If the patient’s heart beat is too slow because the patient’s rhythm is too slow, the pacemaker senses this slow rhythm and “kicks in” additional beats, bringing the patient’s rate up to a rate more compatible with life.)
Generally, the insertion or “implantation” of a pacemaker is considered minor surgery. In most cases, only sedation (and not general anesthesia) is utilized. Local anesthetic is used to numb the area over where the pulse generator will be placed. An incision is made and a “pocket” is formed in the area overlying the muscle on the outside of the chest wall. The pocket needs to be big enough to house the pulse generator, most of which nowadays are about 3 inches by 2 inches in size, and are less than one-half of an inch in thickness.
The pacemaker leads are made of a wire covered by a flexible insulating substance. These are introduced into a vein near the site of the pocket, and then advanced through the large veins that lead to the heart. Fluoroscopy is used to visualize the leads and heart structures so that the leads can be placed in a satisfactory position. They are then “tested” to see how well the underlying electrical activity of the heart is sensed (“sensing threshold”), and how little energy is required to capture the muscle (“pacing threshold”).
The leads are inserted into the pulse generator, and tightened down with a specialized screwdriver. The pulse generator is then usually secured to the underlying muscle with a suture. The wound is closed using a variety of techniques. This generally requires about 30 minutes to 60 minutes to complete, although sometimes there are technical challenges that cause the procedure to last quite a bit longer.
Initial Insertion of Pacemaker
A single chamber pacemaker system includes a pulse generator and one electrode inserted in either the atrium or the ventricle. A dual chamber pacemaker system includes a pulse generator and one electrode inserted in the atrium and one electrode inserted in the ventricle. Codes 33206-33208 include subcutaneous insertion of the pulse generator and transvenous placement of electrode(s).
Codes 33206, 33207 and 33208 identify the procedures most commonly associated with pacemaker implantation, the complete operation of catheter and pulse generator placement, including all steps of the procedure. The difference between codes 33206, 33207 and 33208 are limited to the specific chamber of the heart in which the transvenous leads are positioned. All three approaches require passage of a transvenous lead through a central vein (using fluoroscopic control) into the appropriate chamber of the heart with subsequent electrical verification of good pacing and sensing parameters. All three approaches require surgical creation of a pocket for the pulse generator. The insertion of a pulse generator is included in codes 33206, 33207 and 33208. Remember that removal of an old pacemaker and/or its electrode(s) must be coded additionally.
Insertion or Replacement of Pulse Generator (Battery) Only
The procedures described in codes 33212 and 33213 would be performed when a pulse generator reaches its “end of life.” When the battery of a pacemaker or pacing cardioverter-defibrillator is changed, it is actually the pulse generator that is changed. In either instance, the pacemaker pocket would be surgically re-entered, the pulse generator disconnected from the lead(s), the leads tested to verify that they are still functioning properly and a new pulse generator reattached. The only 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. Remember that the replacement of a pulse generator should be reported with a code for removal of the pulse generator and another code for insertion of a pulse generator, either code 33212, for single chamber or code 33213 for dual chamber replacement, and code 33233 for the removal of either. Threshold and functional testing of the existing electrodes is a necessary part of these procedures.
Upgrade of Pacemaker System
In patients with a previously implanted single chamber pacemaker, it may be necessary to upgrade to a dual chamber device. Code 33214 is used to describe the upgrade from a single chamber to a dual chamber system. Most often, a previously implanted ventricular pacemaker is upgraded to a dual chamber device. Occasionally, however, a patient with a previously implanted atrial pacemaker may require the implantation of a ventricular pacemaker. In this instance, code 33214 also applies.
The procedure code described in code 33214 would be performed when a patient who had a permanent single chamber pacemaker develops a specific problem requiring conversion to a dual chamber pacemaker. The most common situation would be documentation of the “pacemaker syndrome” where retrograde P wave conduction is occurring. Usually such a patient presents with symptoms of heart failure secondary to retrograde P wave conduction. Another example might be a patient with idiopathic hypertrophic subaortic stenosis (IHSS) who has had a permanent ventricular pacemaker for many years. In recent years, hemodynamic advantages of dual chamber pacing (vs. single chamber) have been documented. Therefore, it would be appropriate to convert such a patient to a dual chamber unit. This specific procedure requires reopening the pacemaker pocket surgically, placing a second lead into the atrium, verifying that the pacing parameters on the chronic ventricular lead are still satisfactory and then connecting both the new and the old lead to a new dual chamber pulse generator.
<p>Electrode Insertion or Repositioning Subsequent to Initial Insertion
Codes 33215-33217 do not describe initial insertion, but rather a circumstance requiring subsequent insertion or repositioning occurring 15 days or more, for example, when an electrode becomes malpositioned. (15 days or more after initial insertion.)
Code 33215 describes the repositioning of previously implanted transvenous pacemaker or pacing cardioverter-defibrillator (right atrial or right ventricular) electrode.
Codes 33216 and 33217 describe the insertion or replacement of permanent transvenous electrode(s) only (15 days or more after initial insertion), with code 33216 being the single chamber, one electrode, and code 33217 the dual chamber, two electrodes.
Repair of Electrodes
Code 33218 describes the repair of a single transvenous electrode for a single chamber pacemaker or a single chamber pacing cardioverter defibrillator. For example, if an electrode fracture or an insulation defect occurs, it may be possible to repair the electrode. Occasionally, a terminal pin on an electrode may be repaired as well. Code 33220 refers to the repair of two transvenous electrodes for a dual chamber pacemaker or a dual chamber pacing cardioverter defibrillator. If, at the same time, pulse generator replacement is necessary, then an appropriate code is chosen from codes 33212 or 33213.
Removal of Pacemaker And/or Electrodes
Code 33233 describes removal of a pacemaker pulse generator only. (The leads are not removed). Code 33234 describes removal of the transvenous pacemaker electrode in a single chamber system. Code 33235 is used for the removal of transvenous pacemaker electrode (s) in a dual lead system. There are significant differences in the services described in codes 33233, 33234 and 33235. The procedure described in code 33233 is generally straightforward. The pacemaker pocket is surgically entered. The pulse generator is disconnected. This may be done because the old generator or entire system is no longer working and this system is being replaced. The removal of a transvenous electrode, either single or dual lead, can be complicated. Most commonly, removal would be undertaken for an infectious situation. Many times the lead can be extracted by tugging on the lead. However, in other situations, chronic leads are well embedded in the myocardium and simple extraction is not possible without ventricular perforation. When infection is present it is important that the lead be removed. The surgeon often attaches weights to the end of the lead to provide additional traction until the lead is freed from its myocardial attachment. Another method for removal is the use of a snare and extraction device. No matter the method of transvenous extraction, the CPT codes remain the same, 33234 for the single lead and 33235 for the dual leads.
Coders should also be aware that in some cases the electrode (lead) merely ceases to function, and there is no infection. The physician then may choose to simply abandon the lead, leaving it inside the patient, and place another lead. No removal of a lead is done. The CPT code would then either be 33216 for the insertion of the single lead, or 33217 for the insertion of the dual leads.
As evident from the preceding discussion, the coding of pacemakers is fairly complex from the CPT point of view because of the many different procedures that might be performed and the corresponding codes available for these procedures. It is imperative that the coder closely reads the operative report to determine the correct CPT code assignment.
A future issue of CCS Prep! will contain information related to cardioverter defibrillator procedures. For a quiz on this month’s column, please see the online version of this article at www.advanceweb.com/him.
This month’s column has been prepared by Melinda Stegman, MBA, CCS, manager of clinical HIM services, and Beverly Finney, RHIA, senior consultant, HSS Inc. (www.hssweb.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.