+33225: Find out Which Primary Code this Case Study Supports

Here's a real-life case study to see if you can pinpoint the codes this documentation does -- and does not -- back up.

Start by analyzing the report excerpt

An incision was made along the left deltopectoral groove, and an ICD pocket was dissected out, was prepared with extensive dissection.

Three different guidewires were advanced into the left subclavian vein utilizing the Seldinger technique across the open pocket. Then the middle of these wires was used to further a coronary sinus sheath for placement of the left ventricular lead. With some difficulty, we're able to further the coronary sinus sheath in the mid coronary sinus and an angiogram was got. After this a left ventricular lead was then advanced in the lateral cardiac vein and the tip was advanced to the near LV apex. Electrical testing was carried out at three difficult locations and the rest of these noted a lead impedance of 840 ohms and an R wave value of 17.1 mV.

After this, the bipolar right ventricular defibrillator active fixation lead was advanced to the right ventricle, various areas were checked and the lead was finally fixated along the RV.

Hereafter the bipolar right ventricular defibrillator active fixation lead was advanced to the right atrium. Various areas checked and the lead was finally fixated along the RV septum and tested.

Then a bipolar screw in type right atrial lead was advanced to the right atrium while the lead was fixated to the right atrial wall. After this the coronary sinus sheath was removed with the cutting device maintaining a good lead position of the LV lead.

After this, all the three leads were then sutured to the pectoral fascia over the Silastic sleeves. The ICD pocket was irrigated. Soon the leads were then attached to the ICD/BiV device. Post this, the ICD was placed in the pacer pocket after a standard dose of thrombin material in the pocket. The ICD pocket was sutured closed.

The patient was provided propofol and the following establishment of sufficient general anesthesia. Ventricular fibrillation was encouraged. The advice analyzed and delivered three separate DC countershocks, at last at 36V and the patient converted back to normal sinus rhythm. Patient was made to wake up from sedation without obvious side effects.

Add-On Code

The case study appears to be a new implant of a Biventricular Defibrillator with follow-up testing at implant. While going through the first two paragraphs, you should focus on the terms describing placement of the left ventricular lead via the coronary sinus. The right code for this portion is +33225.

Tips for documentation: You may see this lead referred to as either a left ventricular (LV) lead or coronary sinus lead.

For that add-on code, add the primary code

The next few paragraphs of the documentation describe lead fixation for the RV and RA. What's more, the cardiologist attaches the leads to the device, places the device in the pacer pocket, and sutures the pocket closed. One code 33249 covers all of this.

Add-on note: CPT lists 33249 as a proper primary code for add-on code +33225.

Defib Testing gets you the final code

The last paragraph of the case study excerpt describes 93641. As far as defib testing is concerned, you want to see impedance in the documentation.

Term tip: The defibrillation threshold is the minimum energy amount required during ventricular arrhythmia to defibrillate the heart dependably. Being aware of the patient's DFT helps the cardiologist confirm that the cardioverter-defibrillator (ICD) programming will provide enough of a shock to defibrillate the patient's heart.

Add modifiers to at least one code

Code 93641 requires modifier 26 (PC) to indicate you are claiming only the physician work (and practice expense and malpractice expense) for this service. For this code, the Medicare Fee Schedule (Physician) lists a PC/TC indicator of "1". This means you may use modifier 26 with the code.

You may require a modifier on 33225 because it is an add-on code for 33249. However you may need a 59 modifier on the 93641, depending on the carrier. You should not need one, however you never know with carrier's software.

Your practice should hit these points

In a case such as this, the doctor would normally use fluoroscopy, too; but again it is not documented in this case.

No documentation of fluoroscopy means you shouldn't bill fluoroscopy. When fluoroscopy is documented, you should report 71090-26.

ICD-9: The case-study excerpt also does not mention indications for you to choose ICD-9 diagnosis codes.

What's more, check your local requirements for diagnosis codes that support medical necessity for 33225.

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