Finally, a pacemaker may be either permanent or temporary, which will also factor into your code selections.

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1 2015 Cardiology Survival Guide Chapter 15: Pacemakers With more than 30 codes and many variables to choose from, you must weigh your options carefully when reporting insertion, revision, or removal of a pacemaker (or any portion thereof). To narrow your choices, follow these steps and use the charts below to find the exact code you need. For information on monitoring pacemakers, see Chapter 10, "Device Monitoring." Define Your Terms Choosing a proper code means you must know some basic vocabulary that describes pacemakers. To begin with, all pacemaker systems include two basic parts: 1. A pulse generator (battery) 2. One or more "leads" or electrodes. The physician may place, revise, or remove these components either at once or individually, and CPT provides specific, independent codes to describe these various combinations. In addition, a pacemaker may be of a "single" or "dual" chamber variety, with a single chamber pacemaker having just one electrode or lead and the dual chamber pacemaker having two electrodes or leads (one inserted into the right atrium and one inserted in the right ventricle). Some patients may have an additional electrode placed for left ventricular pacing. Again, the type of pacemaker (single- or dual-chamber) used as well as the exact location of the leads themselves will often determine the appropriate code. Finally, a pacemaker may be either permanent or temporary, which will also factor into your code selections. Determine if the Pacemaker Is Permanent or Temporary Coding for temporary pacemakers is relatively easy because there are only a few codes from which to choose. You should report (Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter [separate procedure]) when the physician either inserts or replaces a single-lead temporary pacemaker system. Likewise, you should report (Insertion or replacement of temporary transvenous dual chamber pacing electrodes [separate procedure]) when the physician either inserts or replaces a dual-lead temporary pacemaker system. Because the pulse generator for a temporary pacemaker is external (that is, it remains outside the patient's body and requires no subcutaneous placement), the only billable procedure involves placing the electrode(s). There is no separate code to report pulse generator placement with a temporary pacemaker (see below for information on coding removal of a permanent pacemaker pulse generator). Watch out: Both and are "separate procedures" meaning that they are bundled into many other services, including cardiac and non-cardiac surgeries and diagnostic heart procedures (like electrophysiologic procedures). Then there's removal: For removal of a temporary pacemaker with a single-lead electrode, you should report (Removal of transvenous pacemaker electrode[s]; single lead system, atrial or ventricular). For removal of a temporary pacemaker with dual-lead electrodes, report (... dual lead system). Note that when reporting electrode removal followed by replacement, you should report only the removal codes (because the insertion/replacement procedures and are "separate procedures" and therefore not independently billable with and 33235).

2 Example: The physician must remove a faulty temporary pacemaker electrode of a single-lead system from the left atrium. During the same session, he inserts a new electrode at the same location. In this case, you should report for the single electrode removal. You should not report the replacement (33210) separately because removal includes the replacement. You may properly report repositioning of a temporary pacemaker lead using ( Repositioning of previously implanted transvenous pacemaker or implantable defibrillator (right atrial or right ventricular) electrode). Table 1: Temporary Pacemaker Decision Chart Procedure Type Single Chamber Dual Chamber Insertion Repositioning N/A Removal Turn to These Codes for Complete, Permanent System Procedures When the physician either inserts or replaces an entire permanent pacemaker (including the pulse generator and leads), you would report (Insertion of new or replacement of permanent pacemaker with transvenous electrode[s]; atrial) or (... ventricular) depending on the electrode's location for single chamber devices and (... atrial and ventricular) for a dual-chamber device. Tip: Don t forget to update yourself with the use of modifier KX on claims billed under CPT code range Note that these codes are correct if the physician places the leads transvenously. For epicardial placement, you would use a different set of codes (see below). When the physician removes an entire permanent epicardial pacemaker system by thoracotomy, report (Removal of permanent epicardial pacemaker and electrodes by thoracotomy; single lead system, atrial or ventricular) for a singlelead system removal and (... dual lead system) for a dual-lead system removal. Coding for revisions, repairs, and removals of other individual pacemaker components (electrode[s] and pulse generator) varies, with some services described by a single code and others requiring multiple codes, as described below. Note that the physician also may remove a previously placed single-lead system and replace it with a dual-lead system. In these cases, the appropriate code is (Upgrade of implanted pacemaker system...). This procedure includes removing and replacing the pulse generator, as well as testing the existing lead and placing the additional lead. Table 2: Permanent Pacemaker (Whole System) Decision Chart (Transvenous placement for epicardial placement, see 33202, etc.) Procedure Type Atrial Ventricular Dual Lead Insertion Removal/ Replacement Removal by Thoracotomy 33233, or 33235, , or 33235, * For replacement of single with dual, use Revision/Repair coding depends on components involved: see tables 3, 4, and , or 33235, 33208*

3 Other Removal coding depends on components involved: see tables 3, 4, and 5. Use These Codes for Generator-Only Procedures When the physician does not insert or replace an entire pacemaker system, but rather works on components, you should base your coding on the procedure(s) performed. For procedures involving the pulse generator only, you'll need to know whether the generator is single-, dual-, or multiple-lead. When the physician inserts only the pacemaker generator and the patient has an already existing single lead, you should claim (Insertion of pacemaker pulse generator only; with existing single lead). For the same service but with existing dual leads, the correct code is (... with existing dual leads). And for the same service with existing multiple leads, report ( with existing multiple leads). Remember: If the physician places the pulse generator and electrode(s) at the same session, you should refer to the "whole system" codes ( ), as described above, rather than report separate codes for the pulse generator and electrode(s) insertion. For removal of the pulse generator only, you may report (Removal of permanent pacemaker pulse generator only), regardless of the generator's type (single-,dual, or multiple-chamber). Finally, the physician may, in some cases, simply reposition or relocate the pulse generator (which in a permanent pacemaker system, he would place subcutaneously) by revising the "pocket" in which the generator rests. In such cases, you should report (Relocation of skin pocket for pacemaker). Note, however, that the Correct Coding Initiative (CCI) bundles with many other pacemaker procedures. "Battery change" really means pulse generator replacement: "When the 'battery' of a pacemaker is changed, it is actually the pulse generator that is changed," CPT specifies. In such cases, you should report a single code to capture both the "old" generator's removal and the "new" generator insertion. Choose among (single lead system), (dual lead system), and (multiple lead system). Table 3: Pulse Generator Decision Chart Procedure Type Atrial Ventricular Dual Multiple Insertion Removal/Replacement Relocation of skin pocket Removal Consider Your 'Lead' Possibilities More than half the codes describing pacemaker procedures deal specifically with the pacemaker leads or electrodes, and you must carefully tend to electrode location and the exact type of procedure when choosing from among them. For transvenous electrodes you will find codes to describe insertion, repositioning, repair, and removal of these leads. For a single lead insertion (or one lead of a dual-lead system), you should report (Insertion of a single transvenous electrode, permanent pacemaker or implantable defibrillator). For two electrodes, report ( Insertion of 2 transvenous electrodes, permanent pacemaker or implantable defibrillator). If the physician must reposition an electrode, report (as described above). You may claim electrode(s) repair using either ( Repair of single transvenous electrode, permanent pacemaker or implantable defibrillator) or ( Repair of 2 transvenous electrodes for permanent pacemaker or implantable defibrillator), as appropriate to the number of leads. Take note that you may report electrode repair ( ) separately from pulse generator replacement ( ) at the same session, according to CPT instructions.

4 Finally, turn to (Removal of transvenous pacemaker electrode[s]; single lead system, atrial or ventricular) or (... dual lead system) for transvenous electrodes(s) removal unless your physician must use thoracotomy to facilitate the removal. If thoracotomy was necessary, the proper removal code is (Removal of permanent transvenous electrode[s] by thoracotomy). Table 4: Transvenous Electrode Decision Chart Type of procedure 1 Lead 2 Leads Insertion Repositioning N/A Repair Removal by thoracotomy Other removal Note: These codes apply only to transvenous electrode(s) used in a permanent pacemaker system. Treat Left-Pacing Electrodes Separately CPT clarifies, "In certain circumstances, an additional electrode may be required to achieve pacing of the left ventricle." Such an arrangement is called "biventricular pacing" and may lead to reporting additional codes. If the physician places a left pacing ventricular electrode during the same session as the pulse generator, you should report ( Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (List separately in addition to code for primary procedure)). Note that CPT specifically designates as an add-on code, and you must report it in addition to a code describing pulse generator insertion (such as , , , etc.). For left pacing ventricular electrodes with connection to an existing (previously placed) generator, you should report ( Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator)). This procedure specifically includes generator replacement, if necessary. Finally, for repositioning of a left ventricular electrode, you should claim (Repositioning of previously implanted cardiac venous system [left ventricular] electrode [including removal, insertion and/or replacement of existing generator). Table 5: Pacing (Left Ventricular) Electrode Decision Chart Procedure Type At time of generator insertion Insertion Repositioning Removal Replacement Report removal followed by insertion (33234 and 33224). Consider Epicardial Electrodes Distinctly Also With previously placed generator Finally, you also may bill separately for epicardial electrode placement at the same time as generator placement. (A physician other than the cardiologist may perform epicardial placement, so remember that only the physician who performs the service should report it.)

5 Inserting these electrodes requires either an open thoracotomy (33202, Insertion of epicardial electrode[s]; open incision [e.g., thoracotomy, median sternotomy, subxiphoid ]) or use of the thoracoscope (33203,... endoscopic [e.g., thoracoscopy, pericardioscopy]). Again, CPT rules specify, "Use 33240, as appropriate, in addition to the epicardial lead placement codes to report the insertion of the generator when done by the same physician during the same session." Removal of epicardial leads may occur in the same fashion as transvenous lead removal (33244) or via thoracotomy (33243). Table 6: Epicardial Electrode Placement Decision Chart Procedure Open Endoscopic Insertion N/A Removal N/A Replacement Code for removal followed by insertion. Don't Forget Related Procedures Transvenous You may report 93279, 93280, 93281, 93288, 93293, and 93294, as appropriate, for "electronic or telephonic analysis of internal pacemaker system," according to CPT. You should not report these at time of insertion or revision, though. Read more on them in the Device Monitoring chapter. Try This Coding Example Example: A patient with a single-chamber (atrial) pacemaker develops atrioventricular node disease. The physician upgrades the pacemaker to a dual-chamber system. The procedure involves removing the existing pulse generator and replacing it with a dual-chamber generator, inserting a ventricular electrode/lead, and checking the atrial electrode/lead. Solution: Report the procedure as This is the code for upgrade from a single-chamber to a dual-chamber system. You should not use the dual-chamber replacement code. - Published on