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Code This!

Scenario Week of June 04, 2014:
View Current Scenario

Assign the correct codes for the following scenario using ICD-9-CM and CPT codes:

Preoperative Diagnosis: Complete heart block

Postoperative Diagnosis: Same

Operation: Implantation of single chamber pacemaker and a left ventricular pacing electrode

Anesthesia: Local anesthesia by infiltration of 1% Xylocaine

Indications: The patient is a 56-year-old gentleman with a history of complete heart block. He was noted to have episodes of frequent ventricular ectopy including brief runs of nonsustained ventricular tachycardia.

Informed Consent: The risks and benefits of the procedure were explained to the patient. The patient elected to proceed with the procedure(s).

Approach and Surgical Procedure: The chest was prepped with Betadine and draped in the usual fashion. Local anesthesia was obtained by infiltration of 1% Xylocaine.

A subfascial incision was made about 2 cm below the clavicle, and a subfascial pocket for pacemaker generator was created. Using the Seldinger technique, the subclavian vein was cannulated and through this, a pacemaker atrial lead was placed in the right atrium, to the atrial septum.

Thresholds were obtained as follows: the P-wave was 1.4 millivolts, atrial threshold was 1.6 millivolts with a resultant current of 3.3 mA (milliampere), and resistance of 467 ohms.

Using a second subclavian stick in the Seldinger technique, a ventricular lead was inserted and placed in the left ventricular apex. The thresholds were obtained and were as follows: R-wave was 24.2 millivolts.

The patient was pacing at 100% at 0.4 volts with resultant current of 0.9 mA and resistance of 490 ohms. When we were satisfied with the thresholds, the leads were connected to the pacemaker generator. The wound was thoroughly irrigated with antibiotic solution, and meticulous hemostasis was obtained. The incision was closed in layers with 2-0 Dexon. A compressive dressing was applied, and the patient withstood the procedure very well. He was taken to the recovery room in satisfactory condition.

Please assign the correct ICD-9-CM and CPT codes for the procedure above.


ANSWERS:

CPT Codes
33206 Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial
33225 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (List separately in addition to code for primary procedure)

Rationale
The first procedure was implantation of single chamber pacemaker. In the index of CPT 2014, Professional Edition, under the main term “pacemaker, heart” and subterm “insertion,” the code range provided is 33206-33208. Reviewing this code range in the main section of the book, the code description for 33206 describes an “Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial.” The documentation in the operative report states that “a pacemaker atrial lead was placed in the right atrium, to the atrial septum.” With this information, all of the components listed in the code descriptor are present and it is appropriate to report code 33206.

The second procedure was “left ventricular pacing electrode.” Under the main term “pacemaker, heart” and subterms “insertion” and then “electrode,” the code ranges provided are 33202-33203, 33216-33217, and 33224-33225. Reviewing these codes in the main section of the book, the code description for 33225 describes an “Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (List separately in addition to code for primary procedure).” Per CPT Assistant June 2012, Volume 22, Issue 6, page 3, “Pacing in the left ventricle requires insertion of an additional electrode (lead) through the coronary sinus (33224 or 33225) to pace the left ventricle.” Since the physician’s documentation states the lead was placed in the left ventricle and it was placed at the same time as the insertion of the pacemaker, this would be the appropriate code to report.

Code 33225 is an “add-on” code and is not subject to multiple procedure rules. No reimbursement reduction or modifier 51 is applied. Add-on codes describe additional intra-service work associated with the primary procedure. They are performed by the same physician on the same date of service as the primary service/procedure, and must never be reported as a stand-alone code.

ICD-9-CM Diagnosis Code
426.0 Atrioventricular block, complete

Rationale
In the ICD-9-CM alphabetic index, under the main term “block” and subterm “heart” the coder can select from many terms, but the physician’s documentation states “complete heart block.” The subterm “complete (atrioventricular)” refers to code 426.0. When code 426.0 is referenced in the tabular section of ICD-9-CM Volume 1, the code description states “atrioventricular block, complete”; therefore, this would be the correct code assignment.

 
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