Start by analyzing the report excerpt
An incision was made along the left deltopectoral groove, and an ICD pocket was dissected out, was geared up with extensive dissection.
Three different guidewires were advanced into the left subclavian vein using the Seldinger technique across the open pocket. The middle of these wires were then used to further a coronary sinus sheath for placement of the left ventricular lead. With some complexity, we were in the end able to advance the coronary sinus sheath in the mid coronary sinus and an angiogram was obtained. After this a left ventricular lead was advanced in the lateral cardiac vein and the tip was advanced to the near LV apex. Electrical testing was done at three separate 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 lastly fixated along the RV. Next the bipolar right ventricular defibrillator active fixation lead was advanced to the right atrium. Various areas checked and the lead was in the end fixated along the RV septum and tested.
Post this, a bipolar screw in type right atrial lead was advanced to the right atrium and the lead was fixated to the right atrial wall. Then the coronary sinus sheath was removed with the cutting device maintaining a good lead position of the LV lead.
All three leads were then sutured to the pectoral fascia over the Silastic sleeves; the pocket was then irrigated. Pretty soon the leads were attached to the ICD/BiV device. Then the ICD was placed in the pacer pocket after a standard dose of thrombin material in the pocket. Pocket was then sutured closed.
The patient was given propofol and the following establishment of adequate general anesthesia. Ventricular fibrillation was induced; the advice analyzed and delivered three different DC counter shocks, at last at 36V and the patient converted back to normal sinus rhythm. Patient was awakened from sedation minus obvious side effects.
Find your first stop at an add-on code
The case study appears to be a new implant of a Biventricular Defibrillator with follow-up testing at implant. While making your way through the first two paragraphs, you should train eyes on the terms describing placement of the left ventricular lead through the coronary sinus. The proper code for this portion is +33225.
Documentation tip: You may see this lead referred to as either a left ventricular (LV) lead or coronary sinus lead.
Add the primary code for that add-on code
The next few paragraphs of the documentation describe lead fixation for the right ventricle (RV) and the right atrium (RA). Also the cardiologist attaches the leads to the device, places the device in the pacer pocket, and sutures the pocket closed. All of this is covered by one code: 33249. Add-on note: CPT code lists 33249 as a proper primary code for add-on code +33225. Remember that ‘add-on’ codes are always carried out in addition to the primary service or procedure and must never be reported as a stand-alone code.
Defib testing earns the final code
The last paragraph of the case study excerpt describes 93641. With defib testing, you want to see impedance in the documentation. Generally physicians will state something like ‘Ventricular fibrillation was induced. The device analyzed and delivered 3 separate DC countershocks, at last at 36V and the patient converted back to normal sinus rhythm. The high-voltage impedance was 45 ohms.
Term tip: The defibrillation threshold (DFT) is the minimum energy amount required during ventricular arrhythmia to defibrillate the heart reliably. Knowing the patient’s DFT aids the cardiologist confirm that the cardioverter-defibrillator (ICD) programming will provide enough of a surprise to defibrillate the patient’s heart.
Ensure your practice hits these points
In a situation like this, the doctor would typically use fluoroscopy, as well; however, it is not documented in this case. No documentation of fluoroscopy means you should not bill fluoroscopy. When fluoroscopy is documented, you should go for 71090-26.
ICD-9: What’s more, the case study does not mention indications for you to select ICD-9 diagnosis codes. Minus a VT [ventricular tachycardia] diagnosis or information relating to primary prevention criteria, this cannot be coded. Either you have to have a payable diagnosis for the ICD or data to support adding a Q0 modifier to 33249.
What’s more, check your local requirements for diagnosis codes that support medical necessity for 33225.