There is a CPT Assistant, June 2000 Pages: 5-6 Category: Coding Communication that instructs to not seperately report cardioversions with the EP study codes.
Intracardiac Electrophysiology Update-Part 1 of 2 (June 2000)
June 2000 page 5
Intracardiac Electrophysiology Update-Part 1 of 2
CPT 1994 included many code additions and revisions to reflect the technologic advances in the practice of cardiac electrophysiology. Since then, continued technologic changes have influenced electrophysiologic and pacemaker services. CPT 2000 has added 10 new CPT codes, revised 16 existing codes, deleted two codes, revised introductory notes, added explanatory notes and incorporated new cross-references to more accurately depict current clinical practice.
The implantable loop recorder is a new technology capable of extending the cardiac monitoring period sufficiently to address infrequent or recurrent symptoms associated with the electrical conduction of the heart or rare, but significant, rhythm abnormalities.
A new implantable pacing cardioverter-defibrillator combines the features of a typical defibrillator, with a single or dual chamber pacemaker in one device. The pacemaker or pacing cardioverter-defibrillator heading and introductory notes have been revised and expanded to distinguish technology used singularly (pacemaker) or in combination (pacing cardioverter-defibrillator) in the treatment of cardiac arrhythmias. Because all devices currently being implanted have pacing capability that combine a single or dual pacemaker and a cardioverter-defibrillator, codes 33216-33249 were revised to reflect the insertion and removal of the pulse generator and electrode components with distinction of the techniques required.
Five new codes have been added to the intracardiac electrophysiology subsection of the medicine section to describe the subsequent or periodic electrophysiologic evaluation of the implantable loop recorder and the single or dual chamber pacing cardioverter-defibrillators. Four existing codes have been revised to update terminology and to clarify the intrapro-cedural analysis of pacing cardioverter-defibrillator component(s).
Summary of Changes
The pacemaker or pacing cardioverter-defibrillator heading and introductory notes have been revised to update terminology related to pacemaker and pacing cardioverter-defibrillator technology, which has replaced nonpacing cardioverter-defibrillator technology. The primary expansion of the introductory notes relates to the use of the combination pacing cardioverter-defibrillator device which is designed to recognize and provide anti-tachycardia pacing, single or dual-chamber bradycardia therapy, and ventricular defibrillation therapy.
Codes 33216-33249 have been revised and expanded to differentiate distinct technology used singularly (pacemaker) or in combination (pacing cardioverter-defibrillator) in the treatment of cardiac arrhythmias. The assessment and reassessment of the pacing cardioverter-defibrillator electrodes related to sensing, pacing and electrode impedance characteristics at the time of insertion, repair, revision or replacement is additionally reported using codes 93640-93641.
In concert with the revisions/deletions/additions to the pacing cardioverter-defibrillator codes 33216-33249, the corresponding electronic evaluation codes 93640-93642 were revised. The updated descriptor nomenclature now reflects the new technological terminology and the electrophysiologic procedures used to accomplish each type of evaluation.
Codes 93640 and 93641 have been revised to clarify that "induction of an arrhythmia" is inherently inclusive in defibrillation threshold testing. Codes 93741-93744 do not involve induction of an arrhythmia.
Codes 93640-93642 differ from the new pacing cardioverter-defibrillator electronic analysis/programming codes 93741-93744, in that codes 93640-93642 include defibrillation threshold testing which involves assessment of the device's "sensing" capability regarding the induction of ventricular arrhythmia(s) (eg, ventricular tachycardia, ventricular fibrillation) and the arrhythmia termination process.
A new heading and subsection was added to the cardiovascular system section describing the implantation and removal of an "implantable" patient-activated cardiac event recorder. The implantable loop recorder is a new technology capable of extending the cardiac monitoring period sufficiently to address infrequent, recurrent symptoms. Codes 33282 and 33284 have been added since there was no CPT code assigned to these procedures, which were previously reported using the unlisted cardiac surgery code, 33999. An explanatory note was added to clarify that programming is inclusive of initial implantation. However, for subsequent, or periodic electronic analysis the new code 93727 should be reported.
The impetus is to use an insertable loop recorder for transient cardiac symptoms such as difficult-to-diagnose syncope that is infrequent, recurrent and unexplained. In these cases, the physician seeks to document the heart rhythm coincident with the patient's symptoms. Previously, clinicians relied on Holter monitors and external event recorders for this purpose in an attempt to determine the source of the problem. Implanting and explanting an insertable loop recorder is very similar to the implantation of a pacemaker pulse generator, without leads (see procedure descriptions below) as medically necessary for patient requiring longer term cardiac monitoring. While there are some technological differences between the two devices, the clinical services provided to patients are quite similar.
Code 92960 describes external cardioversion only. Therefore, a new code 92961 has been added to describe intracardiac cardioversion, an effective therapy for patients unresponsive to external cardioversion. The two procedures are quite different. Intracardiac cardioversion requires vascular access, placement of one or more catheters into the heart under fluoroscopy, and a much greater knowledge of electrophysiology procedures. Intracardiac cardioversion is typically employed to convert atrial fibrillation if external cardioversion is unsuccessful or contraindicated. Code 92960 has been revised to a parent code format by the addition of a semicolon to accommodate placement of a new indented procedure describing "internal" elective electrical cardioversion.
Because cardioversion is commonly necessary during electrophysiologic procedures. In these instances, cardioversion is considered an inclusive component not warranting additional reporting. An explanatory note has been added indicating that it is not appropriate to report code 92961 in addition to the electrophysiology procedures 93618-93624, 93631, 93640-93642, 93650-93652 or 93741-93744.
How to Use the Codes?
Codes 33200-33249 and 33282-33284 describe procedures specific to the insertion, replacement, repositioning, removal, and repair of components of distinct technology used in the treatment of cardiac arrhythmias. Insertion or reinsertion of single or dual chamber pacemakers and implantable loop recorder (ILR) systems includes "programming" of the device to meet the individual patient needs. However, "programming" (93640-93641) of pacing cardioverter-defibrillator systems is additionally reported at the time of insertion or replacement.
Programming of a pacing cardioverter-defbirllator includes defibrillation threshold testing which involves assessment of the device's "sensing" capability regarding the induction of ventricular arrhythmias(s) (eg, ventricular tachycardia, ventricular fibrillation) and the arrhythmia termination process. Therefore, it is not appropriate to additionally report code 93618, Induction of arrhythmia by electrical pacing, in conjunction with codes 93640-93642.
Low energy cardioversion is another programmable feature of pacing cardioverter defibrillator systems. Selection depends upon cardioversion thresholds tested at the time of device implantation or during device follow-up evaluation. Therefore, code 92960 is not reported in addition to codes 93640-93642 and 93741-93744. The cardioversion described in code 92960 is elective and is external.
The attached table provides an at-a-glance reference to the use of the various intracardiac electrophysiology procedures. More detailed clarifications are summarized below.
Pacemaker or Pacing Cardioverter-Defibrillator Notes and Codes 33216-33249
Codes 33200-33214 will continue to describe procedures related solely to single and dual chamber pacemakers, without descriptor revision.
Because all devices currently being implanted have pacing capability that combines a single or dual pacemaker and a cardioverter-defibrillator in one device, codes 33216-33249 were revised to reflect the procedural differences of this technology. For example, a dual chamber pacemaker system includes a pulse generator and one electrode inserted in the atrium and one electrode inserted in the ventricle. However, a pacing cardioverter-defibrillator may require multiple leads, even when only a single chamber is being paced. Another procedural difference involves implantation of the atrial lead associated with a dual chamber pacing cardioverter-defibrillator, which requires additional skill and time on the part of the implanting physician.
Descriptor revisions to codes 33216-33249 were made to reflect current pacing cardioverter-defibrillator technology. Codes 33216-33217 do NOT describe initial insertion, but rather a circumstance requiring subsequent insertion or repositioning occurring 15 days or more later. For example, when an electrode becomes malpositioned.
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.
Codes 33233-33235 have not been revised for CPT 2000 and continue to describe the removal (without thoracotomy) of the pacing system elements. In the instance where a permanent pacemaker system (pulse generator and electrode(s)) are removed and replaced with a pacing cardioverter-defibrillator system (at the same operation), the codes 33233, 33234 or 33235 should be reported in addition to code 33249.
Codes 33236-33238 have also not been revised for CPT 2000 and continue to describe the removal of a pacemaker pulse generator and pacing electrodes via thoracotomy for epicardial single chamber systems, epicardial dual chamber systems, or permanent transvenous electrode systems. Removal of an epicardial pacemaker lead requires actual exposure of the heart. Removal of a single lead system (code 33236) requires exposure of a small area of the heart. Removal of a dual lead system (code 33237) usually requires more extensive exposure. The procedure described by code 33238 is used in cases where an infected transvenous lead has to be removed but attempts to remove it via the usual mechanisms (ie, code 33234) are unsuccessful. For a "failed" attempt at transvenous extraction, it would be appropriate to use 33244-52 in addition to code 33238.
If only an implantable pacing cardioverter-defibrillator pulse generator is inserted or replaced, then code 33240 is used to describe the insertion or replacement of an existing device. For subcutaneous removal of an existing implantable pacing cardioverter-defibrillator pulse generator system (pulse generator and electrodes), code 33241 should be reported in addition to code 33243 or 33244, depending on how the electrodes were removed.
Codes 33241 and 33243 have been revised to allay reporting confusion. Removal of a pulse generator does not require a thoracotomy, since the pulse generator is located outside of the thoracic cavity (ie, in a pocket under the abdominal muscles). With current technology, only the electrode system may need to be removed by thoracotomy. Both codes 33241 and 33243 should be reported for subcutaneous removal of a pulse generator (33241) and the electrode system by open thoracotomy (33243). When a pacing cardioverter-defibrillator pulse generator and electrodes are removed and a new system is inserted, it is appropriate to code 33241 and 33243; OR 33244 and 33249. Code 33241 has been revised since removal of electrodes or leads is not an inclusive component of code 33241. Removal of an electrode(s) is first attempted by transvenous extraction. However, if transvenous extraction is unsuccessful (code 33244), a thoracotomy is necessary to remove the electrodes (code 33243). For a "failed" attempt at transvenous extration, it would be appropriate to use 33244-52 in addition to code 33243.
Code 33242 has been deleted, as these procedures are now described in the revised codes 33218 and 33200.
Codes 33243 and 33244 describe the actual removal of the single or dual chamber pacing cardioverter-defibrillator electrode(s) by thoracotomy (33243) or by transvenous extraction (33244) technique. For example, removal may be required to treat an infected defibrillator system or if the patient decides to no longer have an implantable pacing cardioverter-defibrillator.
Code 33245 has been revised to now describe the epicardial insertion of single or dual chamber pacing cardioverter-defibrillator electrodes by thoracotomy (33245). Code 33246 has also been revised to describe the epicardial insertion of single or dual chamber pacing cardioverter-defibrillator electrodes and pulse generator by thoracotomy.
Electrode positioning on the epicardial surface of the heart requires a thoracotomy (codes 33245-33246). Removal of electrode(s) may first be attempted by transvenous extraction (code 33244). However, if transvenous extraction is unsuccessful, a thoracotomy may be required to remove the electrodes (code 33243). For a "failed" attempt at transvenous extraction, it would be appropriate to use 33244-52 in addition to code 33243.
Code 33247 has been deleted, as these procedures are now described in the revised code 33216. The indented code 33249 has been editorially revised as a result of the deletion of its parent code 33247. Code 33249 describes the implantation of a pacing cardioverter-defibrillator system (pulse generator and electrodes), using a non-thoracotomy approach. For removal and reinsertion of a pacing cardioverter-defibrillator system (pulse generator and electrodes), report 33241 and 33243; OR 33244 and 33249).
Cross-reference notes have been added to provide clarity in the appropriate use of these codes, based on the procedural technique and the device component(s) involved. Since epicardial electrodes are not routinely removed and reinserted, the added cross-reference does not include codes 33244 or 33246.
Intracardiac Electrophysiological Procedures (Codes 93640-93642, 93727, 93737, 93738, 93741-93744)
Codes 93640 and 93641 are intended to be reported in addition to the appropriate insertion code(s) at the time of implantation or replacement of the single or dual chamber pacing cardioverter defibrillator electrode leads (93640) or pulse generator (93641).
Code 93640 is reported when the pacing cardioverter-defibrillator electrode leads are implanted during insertion but are not connected to the pulse generator. When a pulse generator is connected and the entire system is tested, then code 93641 is reported.
Code 93642 is intended to describe subsequent or periodic electrophysiologic evaluation of a previously-implanted device (including induction of cardiac arrhythmias), performed in an electrophysiology laboratory.
Code 93727 was added to describe subsequent electronic analysis and /or reprogramming of the implantable loop recorder system (33282). Code 93727 includes retrieval of recorded and stored ECG data, physician review and interpretation of retrieved ECG data and reprogramming. Insertion of an implantable loop recorder system (33282) includes initial programming. Therefore, it is not appropriate to report 93727 at the time of initial implantation of the loop recorder.
Patient-Activated Cardiac Event Recorder (33282, 33284)
Codes 33282 and 33284 have been added since there was no CPT code assigned to these procedures, which were previously reported using the unlisted cardiac surgery code, 33999. An explanatory note was added to clarify that programming is inclusive of initial implantation. However, for subsequent, or periodic electronic analysis of the event recorder, the new code 93727 should be reported.
Internal Cardioversion (Code 92961)
Code 92960 describes external cardioversion only. Therefore, a new code 92961 has been added to describe intracardiac cardioversion, an effective therapy for patients unresponsive to external cardioversion. Code 92960 has been revised to a parent code format by the addition of a semicolon to accommodate placement of a new indented procedure describing "internal" elective electrical cardioversion.
Because cardioversion is commonly necessary during electrophysiologic procedures. In these instances, cardioversion is considered an inclusive component not warranting additional reporting. It is not appropriate to report code 92961 in addition to the electrophysiology procedures 93618-93624, 93631, 93640-93642, 93650-93652 or 93741-93744.
* Do not report 93618 in conjunction with 93640-93642.
** Do not report 92961 in conjunction with 93640-93642, 93741-93744.
***Epicardial removal and reinsertion not usually performed.