We're going to give it about two minutes to let folks get logged in and join the webcast today. Good afternoon, everyone. If you're just joining, we're going to give it about another minute to give other people time to get logged into the webcast. Good afternoon, everybody. I'll give it about another 15 seconds and then we'll get started. All right, well, we'll go ahead and get started. Good afternoon, everyone, and thank you for joining us today for our second part of our EP series this year. My name is Jamie Quimby, and I'm the Director of Coding with our Revenue Cycle Solutions Department with MedAxiom. Today, I'm going to cover EP device procedures. If you're new to coding this area, today's presentation is meant to give you a good foundation of the guidelines and all the different reporting options. Actually, when I was putting this deck together, I did not realize how many different device reporting options we have now. We have a lot that are still stuck in category 3, so we're going to cover everything today. Then if you missed our first series, I presented that three weeks ago, and that topic was on EP studies and ablations. If you're interested in hearing that presentation, the recorded presentation is on our MedAxiom Academy website. For the third series, I'm aiming to do that one in the summer, most likely in July, and I'll cover for that topic, it'll be EP device monitoring services. I did get a lot of great feedback on the last presentation and a lot of people requested to do in a more advanced session. I'm going to plan to do that one during our bootcamp series later this year in December. That presentation will be heavily focused on coding real cases that are more complex to this specialty. Definitely stay tuned for more details for the registrations for those next two EP webcasts. Just a little housekeeping. To access the slides for today's presentation, if you click on the chat box, there'll be a PDF version that you can click on and download. We do also upload a copy of that PDF to our MedAxiom Academy website as well, so you'll have option to download it from there later. Please do not use the chat box for anything else, especially questions. We do have a separate Q&A box that you can type your questions in. Please keep your questions on topic though, and then I will try to get to the questions at the end, but I do have almost 100 slides to cover with you today. If I'm not able to get to all of them, I will compile them and we will put that on our MedAxiom Academy website as well, so you'll have a reference or a resource that you can go back to download. With our MedAxiom Academy platform, you can now get your coding CEU directly from the site. The next two slides will guide you through how to do that. We do ask for one to two business days to allow our team time to get everybody's certificate uploaded to your personal account. You do have to launch the webinar in order to obtain your CEU credit if you're listening to it live. We are offering the three-part series as an on-demand option as well. If you're unable to listen to the live presentation, you will have the option to listen to it on demand, and then you would have to take a 15-question quiz to then obtain that CEU. If you're listening to it live today with us, then you will not have to take that quiz to obtain the CEU certificate. This slide is just a screenshot of how you would download your CEU certificate directly from your MedAxiom Academy account. Once you log in, you're going to click on the presentation that you're looking for, and then there will be a little box that says click to claim your CEU. Then once you do that, it'll give you the option to download it onto your computer or you could print it, whatever your preference would be. We're going to get started since we have a lot to cover today. I'm going to start with covering the two most common devices that we see, which is our permanent pacemaker and our permanent implantable defibrillator systems. I'm going to just give you a brief background and define the two devices right now. For a pacemaker, it's a small device that's placed in the chest or the abdomen and it's used to help control abnormal heart rhythms. This device uses electrical pulses to prompt the heart to beat at a normal rate. A pacemaker can relieve some arrhythmia symptoms such as fatigue or fainting. You can see here in the picture that the generator was placed in the patient's chest and it shows that there is a lead placed in that right atrium and in the right ventricle. This would be your standard dual chamber pacemaker system. It is probably the more common pacemaker system that we do see implanted. Now, our implantable cardioverter defibrillators are what we commonly refer to as an ICD device. This is a specialized device that is designed to treat many different dysrhythmias. It is specifically designed to address ventricular tachyarrhythmias. ICDs have revolutionized the treatment of the patients that are at risk for sudden cardiac death due to that ventricular tachyarrhythmia. The device delivers pacing signals and shocks as needed due to the patient's condition. There's different types depending on your lead. This is actual definitions from the AMA in your CPT book. CPT defines a single chamber pacemaker or defibrillator system that would include a pulse generator, and then it has one electrode or lead that is inserted in either your atrium or your ventricular. A dual chamber system would consist of your generator, and then there's two electrodes or two leads that are inserted. This could vary depending on the patient's condition and what is needed. For a dual chamber, you may have a right atrium and right ventricle leads, or you could have a right ventricle or a right atrial, then you would have a lead placed in the coronary sinus to pace the left ventricle. It could be either option just depending on what is needed for that patient to treat their condition. Then to meet the definition of a multi-chamber system, it would include your pulse generator, of course, and then you have three electrodes or three leads. You're going to have a lead in your right atrium, your right ventricle, and then that coronary sinus to pace the left ventricle. Cardiac resynchronization therapy, this is a term that if you currently code these services, you see this documented often. They are typically abbreviated, so you may see the CRTP, which the P is for pacemaker, or you may see a D for defibrillator. These systems have been used to describe biventricular pacing, but can be achieved by left ventricular pacing only, and implanted CR device is a medical device that they use in the CR therapy. It resynchronizes the contractions of the heart's ventricles by sending tiny electrical impulses to the heart muscle, which can help the heart pump blood throughout the body more efficiently. Again, there are the two types of devices. You have one for the pacemaker system and then one for that defibrillator system. Just to break down the two, with the pacemaker device, it would work like a traditional pacemaker system, by keeping the heart from beating too slowly. The device has that additional lead placed on the left side of the heart and that left ventricular to make the left ventricular beat at the same time as the right ventricular. The goal of that is to improve the left ventricular function, reducing pre-systolic mitral regurgitation, and improving the LV diastolic filling time. Most patients may need a CRTP device if they have symptoms of heart failure, despite medication, lifestyle changes, the heart is still beating too slowly, or the left side of the heart is beating out of time with that right side. Similar with the defibrillator system, again, patients most likely are going to have that heart failure. They previously had or are at risk for having that ventricular tachycardia or ventricular fibrillation, which would cause the heart to beat too fast. Again, the purpose of that left ventricular lead is to help keep it in sequence with the right ventricular chamber. Now we're going to start covering all the coding and reporting options available. We're focusing right now just on our pacemaker and defibrillator systems. There are four main essential categories when we're looking at generator coding options for these services. You have your new implants, you have your generator changes that have no lead involvements, you have a generator change that involves a lead procedure, and then you have a generator that is being attached to an existing lead. In your CPT book, there's a table in there right before you get to the device codes. That is very helpful. They give you some different scenarios, and depending on whether the patient would have that pacemaker or defibrillator, they show you the different options for reporting. We'll start with category 1, which is what a new system. This would be the patient's getting a brand new system, which would include an insertion of both the generator and any leads that are placed in the right atrial or right ventricular or both. Fluoroscopy is not separately billable with these services. If they also end up having a left ventricular lead, then you can separately report that. I will cover the LV lead codes in an upcoming slide, so we'll look at that in more detail a little later. DFT testing is also separately billable. This is separately reportable with the defibrillator implants. Again, we'll cover the DFT coding a little later as well. These are the codes for a new system implant. Remember, we're just talking about a pacemaker and defibrillator. For a pacemaker, it's going to depend on the generator, obviously, and then the lead that they end up getting implanted. If you have a right atrial lead, a right ventricular lead, or if you get both an atrial and ventricular. Again, these would be single, this will be your dual chamber. For a defibrillator, they simplified it, and it's only one code, and it doesn't matter if it's a single or dual chamber. Again, it would apply to your right atrial or right ventricular lead or both. Category 2 is our straight generator changes. They're taking out the generator because it's at the end of life, and they're going to put in a new one. No right-sided lead procedure is needed for this, so the coding is pretty straightforward. You might see some common terms like ERI, which is elective replacement interval, or EOS, which is end of service. What they're talking about is that battery is at the end of its life, and they have to replace it to keep the system working. Again, reporting options depending on what the generator is being attached to. Again, pacemaker and defibrillator reporting options, and this would include the removal of the generator with the replacement of a new generator. Category 3 is a generator change that has a right-sided lead procedure involved. It's a common question I get. There's actually a CPT assistant article on this as well. But again, when you're looking at the generator change, and that it's involving a lead procedure, you have to verify in the body of the report first whether the lead involved was on the right side or the left. If it's on the right side, CPT guidelines instruct you to code what was removed, and then you code what was implanted. We'll have some case examples to go over today, so just keep that in mind. If it's just the left-sided lead, say they're getting a generator change, and then they already have a dual chamber system, and the generator is at the end of its life, but the patient's conditions are continuing to advance, and they want to place that left ventricular lead. Well, that's a left-sided lead. For that scenario, you would code the generator change code and then the left ventricular lead insertion. But if you have a right-sided lead involved, you code what was removed, and then you code what was implanted. These are the lead removal code options here. Actually, I think I skipped too fast. No, I didn't. Sorry. Getting ahead of myself. If they have a lead removed, then you have different reporting options just depending on whether they have a pacemaker system or that defibrillator system, and then again, the method of how the leads were removed to, whether it was transvenous or through that thoracotomy. If a lead is capped, there is no billing for that. That means they just put a cap on it and they left it in place, so there's no reporting if you have a capped lead. If they remove that generator and they got the right-sided lead involved, like I said, you have to report what was removed and then you report what was implanted. If you have to report the removal of the generators, these are the two reporting options depending on that device that they're having taken out. Then the last category is that generator attached to existing leads. This one's not as commonly reported, but I actually do have a case example that I will cover with you today on this actual category. This is when a patient has an existing generator that's being taken out. No lead procedure is involved, but they're changing the device from one system to another. All you're putting in is a new generator with the other device. That's the most common reporting for this. In the case example that we'll cover later, the patient is downgrading from a defibrillator to a pacemaker. They left the leads in place, but they're taking out the ICD generator and only putting in a pacemaker generator. That's when you would report this because we had no lead procedure involved. Again, these are the reporting options depending on the type of generator that you're putting in. Like in the example that we'll cover later, because they have the defibrillator generator taken out and we have a pacemaker generator put in. If it's a dual-lead system, most commonly, it would just be a 33213. You would also code the removal of that defibrillator generator though, so that 33241 and then the 33213, just for an example. Some additional details. Here is our left ventricular lead coding options. A left ventricular lead that is implanted at the time of a generator procedure. It's an add-on code, the 33225. Remember, this would need a primary CPT code in order to bill for it. The LV lead was implanted along with the generator. You could either have a new system being placed, a brand new system, or they could just be getting a generator change out and then the addition of that LV lead. Just depending on the reporting options and what was done during that case. If the patient is not having anything else done, they're just coming in to have the LV lead implanted and it's being attached to all the existing equipment that's already in, then you would report that 33224. That is not an add-on code, that is a primary procedure where they're just inserting the LV lead and attaching it to the existing generator. 33226, this is if they would have to reposition the left ventricular lead. I don't see a ton of those where we have to do that, but just if they do have to reposition that has its own code. Now, later in the presentation, because I get asked this a lot, what if they're placing a left bundle branch lead and the provider is documenting it as an LV lead? We're going to cover this in great detail and I actually have two case examples today we're going to cover that have this. A left bundle branch lead would not fall under this category because it's not being placed in that cardiac venous system to pace the left ventricular. Again, we're going to cover this in great detail later in the presentation, and I do have two case examples, so we'll talk those out as we get to those. This is some guidance from CPT assistant. If a left ventricular lead is implanted at the time of a generator change, would you report the LV lead code out on that 33225, and that generator change code reflecting the system the patient receives? Again, yes. As long as there's no right-sided lead procedure involved, it would just be the generator change code with the addition of the new LV lead with that add-on code, the 33225. Most commonly, just to talk it out, maybe a patient has a dual chamber pacemaker and they're going to go and change the generator and add that LV lead. The patient would be leaving the cath lab with a multi-chamber system. You would code the 33229 for the pacemaker generator, and then that 33225 for the addition of that LV lead. In this example, it's a defibrillator system, essentially. His bundle leads. We're going to cover his bundle leads, and then we're going to cover left bundle branch leads, because these are starting to be more popular. But to start with the his bundle lead, how do you report it? Well, you're going to report it to where the lead is placed. His leads can now be placed for that resynchronization therapy, but the lead is placed at the bundle of his either above or below that tricuspid valve in the septum. Current guidance is to code the procedure to the location of the his lead placement. If it's placed below the valve, it's going to be placed in the RV septum. If it's above, I don't see him commonly put in the above, but it can happen. But then you would code it as a right atrial lead. Again, it's just going to depend where in the septum they place the lead. Coding can vary just based off that. Another thing to point out with these is sometimes the provider may document that they're doing his bundle recording. Now, if you look at the CPT definition of the code, it specifies it's reportable when trying to identify a tachyarrhythmia for a separate distinct procedure performed. When they're doing the his bundle recording, it's like the venogram when they're placing an initial lead. It's considered road mapping because they're not doing it for diagnostic purposes. They're doing it to help aid and place the lead in the appropriate location. You would not report the his bundle recording with a his bundle lead implants unless it's done as a diagnostic reason to identify a tachyarrhythmia. Now, again, same thing with left bundle lead reporting. You can see in the picture here, so you have your his bundle located here, and then left bundle is down a little bit lower, where your left ventricle is way down here. Right in here is your septum. Again, current guidelines, you're going to go to the lead location where it's placed. Most commonly, almost all the left bundle branch leads that I see are placed in the RV septum. If you have a provider that's saying they're placing a left bundle branch lead and they're calling it an LV lead, that's not correct. I do think there's a need for a code to be created for this, but current guidance is we don't have one and you would code it to where it's placed, what chamber it's placed in. Again, if it's being placed in the RV septum, it's a right ventricular lead. There are some societies out there that say to report unlisted. Our recommendation, again, is to code it to the placement of the lead itself. You would have to check with your carriers. That's my best guidance I could give on that. If you do decide to report unlisted, I don't know if any folks that currently reported unlisted if they have any success with reimbursement. Again, just check with your payers if you do want to try to report unlisted, but the cases I have today, they're coded to the placement of the lead. Again, we'll talk through those as we get to those later. All right, a pacemaker upgrade. This is when a patient has a single chamber pacemaker system and they're upgrading it to a dual chamber system. The 33214 includes everything involved, so it's taking out a generator, putting in a new one, and putting in that additional lead. I don't see this one coded too often anymore. Just lead procedures only, so there's different reporting options just depending on what happened. If they're inserting a single lead, whether it's a pacemaker or defibrillator, or if they're going to insert two, whether it's epicardial placement, if they have to reposition it or do any kind of repairs. Just, again, different reporting options. Most times when I am reporting any of these codes, most times they're within a 90-day global of the initial implant, so just keep in mind if you are reporting them and you're within that 90 day reporting period from the initial implant. So you're in that global period, you're going to want to append modifier. You know, obviously most likely it's not going to be a planned event. So probably modifier 78 is going to be the best reporting. So it's just going to vary again. Pocket relocation. So way back in the day, we used to have a revision code that went away. So we don't have anything for that now. So the pocket relocation means the patient had to have the pocket moved from one location to another. So if they're just going in and to the bigger pot or they go in in the existing pocket and maybe cleaning it out a little bit, maybe the patient's having pain at the pocket site, that is not going to fall under here because they're not actually relocating the pocket. So documentation's key for this to be supportive. So again, relocation means they're moving the pocket. And this is a CPT assistant article on this that's from November of 2014. So again, relocation of a pocket, whether it's pacemaker or defibrillator, could be medically necessary depending on the clinical circumstances, such as an infection or erosion. Sometimes I see patients are just complaining of discomfort at the site. So the provider's going in to address it. Relocation of a skin pocket may be performed as a standalone procedure, or it can be performed at the time of a generator or lead procedure, not the initial. The initial includes creating the pocket and all that stuff. So this would be on an existing device. So when the skin pocket relocation is performed as part of a removal of an existing generator followed by replacement of a new generator, the pocket relocation can be reported separately. So this would be like they're going in and taking the generator out, putting in a new one, but they're also creating a new pocket and placing that new generator within that new pocket itself. So that would be an instance where CPT is talking about here that you could report both. All right, so this is the DFT testing or defibrillator testing. It's also sometimes called NIPS, which means non-invasive program stimulation. The purpose of this study is to ensure that the cardioverter defibrillator or the ICD and the leads are positioned well and working properly and to guarantee proper function of the device in the future. To test the leads, the physician records cardiac electrical signals from the leads and paces the heart through leads. The physician attaches the leads to that generator and then the physician uses the generator to pace the heart into an unstable arrhythmia. That is part of how this code is defined. They have to induce an unstable arrhythmia and then they use the device to shock the patient back out of that arrhythmia. So that is what DFT testing is. There's different reporting options, as you can see, depending on what the documentation supports. Most commonly, it's the 93641 that I see. I do want to point out if they are getting the subcutaneous ICD, that 93644, when we get to that part of the presentation where we cover that device, the DFT testing is not reportable at the time of the implant of that device. Now, if you're just implanting a traditional defibrillator and they do the DFT testing, they induce ventricular fibrillation and then they use that device to shock the patient out of the V-fib, that's when you would report the DFT testing. All right, anti-tachycardia pacing or ATP. This refers to the use of pacing stimulation techniques for termination of a tachyarrhythmia. There's a code specific for a pacemaker system. For a defibrillator, the coding can vary just depending on what all was done. So again, for a pacemaker system, the 93724, this is defined as an electronic analysis of the pacemaker system. It would include any EKG recording, programming of the device, induction and termination of the arrhythmia via the pacemaker system. And then along with any interpretations of the recording. So all that's included in the 93724. For a defibrillator, there's no specific code like we have for the pacemaker. So again, it's gonna depend on what is documented in the report to see what options you may have. If the documentation shows the patient arrives to the lab already in an unstable arrhythmia, the provider then uses the device to shock the patient back into a stable arrhythmia, then you would report the service as an unlisted. If the documentation shows the patient is being seen to evaluate their device and the provider induces that unstable arrhythmia, then they use the device to shock the patient, that would fall under our DFT testing. But because it's not at the time of the implant, you're gonna be looking at that 93642. So again, it's just gonna depend on the documentation that you have for that case. All right, common question here, venograms. So it was kind of in line with what we just talked about, the HIS bundle recording with the HIS lead placement. So if the venogram is being done to help lead or guide in the placement of that lead, it's not separately billable. If the provider has to do a venogram due to a suspected blockage or any other medically necessary reasons, maybe the patient's complaining about pain or discomfort or they have symptoms, so they're not just doing it to help place the lead, then you may be able to report it. It's just gonna depend on what is documented in that medical necessity. So this is a Q&A from CPT assistant where they're asking if the venogram is separately reportable during a device procedure and CPT says, no, if the service is described, if it's not described as a diagnostic venogram, but rather used for guidance of the leads to facilitate that entry, then you would not separately report the venogram. And again, ultrasound guidance, another common question. This is common to be done on most of our EP procedures and unfortunately, Medicare says no. So you cannot report ultrasound guidance with any EP procedure that we do. And unfortunately, Medicare was so nice that they actually listed the code ranges and you can see 33202 through the 33249 is all of our device procedures and then they also reference our EP studies and ablation. So unfortunately with this, fluoroscopy is not billable and any ultrasound procedure is not separately reportable for our EP services. All right, so now we've got a couple of questions All right, so now we got other systems to cover. Temporary pacemakers, so again, this would be, maybe the patient went into complete heart block, they're unstable and they get brought to the cath lab urgently and the provider has to place that temporary system. Reporting for this is going to vary. So there's an NCCI edit where no modifier is allowed to override. So if you do any other EP procedure same day, so say they bring them in, they put in the temporary system and then they got the patient stabilized and now they're going to go ahead and put in a dual chamber pacemaker. Well, because you're doing it same day, same session, you cannot bill for that temporary system. It's not allowed, it will bundle and there's no modifier allowed to override that edit. So again, it's just, if it's done as a solo procedure and then maybe they wait till the next day to see how the patient stabilizes, then you could bill for it because it's not done on the same day. The temporary pacemaker pretty much bundles with any cardiac procedure we do. So maybe the patient has a pacemaker or a temporary system put in by an interventional cardiologist and then they get brought to the cath lab and they have a cardiac cath done too. Same thing, it's still bundled. So it doesn't matter whether, doesn't matter the specialty essentially. If they have another procedure done same day, then it's going to bundle unfortunately. But just talking about EP there, it would definitely bundle and no modifiers allowed. So again, here's the edit from the NCCI manual where they say it is not separately reportable. And again, they reference all of our codes for EP. So one of those strict rules that they just don't allow a modifier. All right, leadless pacemaker. So we have different reporting options now for this as of the beginning of this year. So we're going to start with the one that's been in place for the last several years. This is our leadless right ventricular pacemaker system. You can see on the pictures, this is what the devices look like. They're pretty small. They almost look like the size of a bullet in a sense. So they're much smaller than the conventional pacemaker system which is comprised of that pulse generator. And then they have those leads that get tunneled and connected to that generator. So these procedures are much, you know, not as detailed or invasive, I guess you could say. So the procedure typically has the lead implanted via the femoral vein. It's a small device and it's designed to be fully retrievable. So it could be repositioned easily or pulled out and, you know, replaced if needed, all that stuff. So a little bit of an easier, easier for the patient, I guess you could say. Reporting options here. So you have 33274 for the initial insert or replacement. And then you have a 33275 for the removal. Now, if the patient has to have maybe the systems, you know, coming at the end of its life and they have to have it removed and then replaced, there is an edit with these. You cannot report these two codes together. There's a no modifier rule allowed. So if they had the system removed and a new one put in, you would only be able to report the insertion. You also wanna check with your payers on any policies with these. Medicare, when these were still category three code, they have an NCD out and it does require a Q0 modifier with the secondary diagnosis of that Z00.6 for the clinical trial. Now, again, this is gonna vary now since these graduated to a category one code several years ago. Some carriers no longer require you to attach the registry and the Q0 and all that, but some still do. So check with your carriers is my best advice. They do vary across the country. Just keep in mind, if they do still require that trial number, you make sure you're getting that Q0 with the Z00.6 secondary diagnosis appended. Here is our subcutaneous implantable defibrillator that I was talking about. So this is a system that does not let you build a DFT testing at the time of the implant, but just to give you a rundown of the device itself. So this system is implanted to help avoid the need for the transvenous placement of the electrode. The system requires a pulse generator with greater defibrillation energy compared to the traditional ICD generators, as well as the subcutaneous electrode lead. Implantation is completely subcutaneous. It's performed by tunneling the lead under the skin. There's no hardware within the heart or blood vessels. The subcutaneous system also differs from that traditional ICD system in several aspects. The subcutaneous system cannot pace the heart, whereas the traditional defibrillator can. The transvenous system may be inserted in a single chamber, meaning maybe it's being placed in the right ventricular, or it could be done in dual chambers, whereas this system is not. And then the transvenous device, again, may use a combination of any of that anti-tachycardia pacing, low energy cardioversion, or the defibrillating shocks to treat any ventricular arrhythmias, whereas the subcutaneous system can only provide the defibrillating shocks. So that's just a little bit of the difference. Usually, if you're coding a case like this, the provider is very detailed, and they will specifically reference that this lead is being tunneled. So that's how you know it's not a traditional defibrillator system. Again, these are the coding options, depending on that case that you're looking at. The initial insertion would be the 33270. If they're only doing a lead procedure here, you got the 33271. If they're removing the previous lead, the 33272, or if they're repositioning the lead. Now, what if they already have an existing subcutaneous system, and the generator is at the end of its life, and they're only taking out the generator? Well, you're gonna report that with just your traditional generator code. So because it's a single lead system, it's gonna be that 33262 for that defibrillator generator being replaced. Again, no DFT testing reportable with these services. All right, subcutaneous cardiac rhythm monitor, what we commonly call as a loop recorder, or an ILR, which is an implantable loop recorder. These are very common. These are placed to monitor a patient. So if maybe the patient had a CVA, and the provider's trying to rule out any underlying atrial fib that maybe the patient has not ever had a diagnosis of, or the patient has symptoms where they just have syncope is common, palpitations, dizziness, that kind of stuff. And the provider wants to monitor the patient a little bit longer term than just doing a traditional event monitor, or ZioPatch monitor, or one of those. They may place these. They're pretty small. These actually used to have a 90-day global period assigned to them several years ago, which was crazy. They're actually, the device itself is about the size of a paperclip. It's a very small device. They just make a tiny incision in the skin, and then they insert it. So it's not where they happen to create a pocket like they do with the pacemaker defibrillator. So these no longer have that 90-day global associated with them. That was updated several years ago. But these are the reporting options. 33285 is for your insertion. 33286 is for the removal. Now, there is an NCCI edit reporting these two together. And there are times where maybe the patient, because these also don't last forever, so the generator for the system itself may be at the end of its life, and the provider still wants to continue monitoring the patient. So they may take the system out and place a new one. Now, if it's placed within the same pocket, that's where you're gonna get your NCCI edit. A modifier is allowed to override this edit, but you would have to put it in a new spot. You can't put it, if you take it out and then insert the new one in the same pocket, then you only report the insertion. If they take it out, suture the patient up, and then place it in a different spot, that's where you could report both, and then you would put your modifier 59 or your X modifiers on that 33286. So again, it's just gonna depend. But if it's in the same pocket, you only bill the insertion. All right, now we have some new technology codes to cover. There's several. We're gonna start with our dual chamber leadless pacemakers. These were new. I believe these became active last July. I have yet to see a case on these new codes, but I'm waiting patiently to see one. I do see the single chamber in the right ventricle, because those are the more common ones that we've had in place for several years. But if you do have a provider that's doing these, so it's just gonna depend on the reporting options. There's insertions, removals, and then if they just do an insert with a removal. So these are just the insertion only codes, and it's gonna vary on what all was done. So a dual chamber pacemaker system is going to include two pulse generators with the built-in battery and that electrode. So the little bullet kind of shaped system there. Implantation of the system is performed using the catheter under fluoroscopy guidance and obviously with that transvenous access. Once the pacemaker is implanted in the right atrium and then one in the right ventricle, your code 0795T would describe the insertion of a complete dual leadless system. It can be done in stages though. So if you have a pacemaker where they're doing the right ventricle at the initial procedure, and then they're planning to bring the patient back to do the right atrium at a subsequent visit, then that's when you could code the component codes here. So the provider knows he's going to be hitting in that dual system, but for whatever reason, they're gonna do one lead at a time. So then that would be you breaking up the coding. This is for the removal only code so that they would have the system completely moved out. Now, if they're doing the full system removal, both of them at the same time, it's gonna be the 0798T, but if they're gonna do it in stages where they take one out first and then bring the patient back, then the coding would vary, just depending on what all they do. This would be a dual chamber leadless pacemaker removal with replacement. So maybe the patient's device is at end of its life and they took the existing device out and put in and replace it with new stuff. That's when you would report these. So again, coding varies depending on what is supported by your documentation. And then new as of this year in January, we got a single chamber leadless pacemaker for the right atrium only. So again, it's gonna depend your documentation. Regarding both systems, you're gonna wanna check the clinical registries for any active clinical trials that your group may be involved with. And then of course you're gonna make sure you're getting the Q0 modifier on these as applicable along with the registry number and then that secondary Z diagnosis code to show it's in that clinical trial. So again, just make sure you're checking with your provider and the hospital systems that you're working with to verify those details. All right, the next three devices I'm gonna cover, I don't see often, but these were created back in 2019. So there's three different ones, like I said, that we'll cover. The first of the three is the wireless cardiac stimulation system for left ventricular pacing. This provides biventricular pacing by sensing the right ventricle pacing output from a previously implanted conventional device such as a pacemaker or defibrillator, and then transmitting an ultrasound pulse to wire the electrode that's implanted on the endocardium of the left ventricle. This would then emit a left ventricular pacing pulse. And again, just to kind of break down the device itself, the system consists of two components. It has the wireless endocardial left ventricular electrode, and then it also has a pulse generator. The pulse generator has two components. It has a transmitter and a battery. The electrode or the lead is implanted transarterially into the left ventricular wall and powered wirelessly using ultrasound delivered by a subcutaneously implanted transmitter. It has two subcutaneous pockets that are created on the chest wall. One is for that battery, and then one is for that transmitter. And then these two components are connected by a subcutaneously tunneled cable. I have not seen one of these yet, but if you are performing these, then you do have some coding options. There were some revisions at the start of 2024, and we covered all this in our bootcamp series last December. But again, just depending on what all is done, you know, these are your reporting options. You can see what was revised on the new codes or what ended up being a brand new code for this year. All right, the second of the three that we're gonna cover, again, these were created back in 2019. This is our intracardiac ischemia monitoring system. This is an implantable cardiac device. It's designed to detect rapid ST segment changes, ST shifts that may signify major cardiac events, such as coronary artery occlusions that can be caused by life-threatening vulnerable plaque ruptures. Once an ST shift is detected, the system is designed to alert patients to seek medical care. It does it by delivering a series of vibrating, auditory and visual warnings. AngelMed Guardian System is who manufactures this. So you may see it referred to as that or the intracardiac ischemic monitoring system. And these are the available codes for reporting for this device. Again, these are all category three as well. Again, just depending on what you have supported by your documentation, whether it's the initial insert or if it's a replacement or a complete removal. All right, and then the last of the three devices is the permanent cardiac contrability modulation system or what we typically call CCM. I have seen a couple of these in the last several years. They're not as common obviously but we have coded some. This device consists of a programmable and rechargeable generator. It's powered by a lithium battery. The device is implanted within a pocket on the right side of the chest and typically below the collarbone and then it has an electrode fixed on the carotid sinus. One incision allows the access to the cervical nerve and another incision is made for the insertion of that right ventricular lead or electrode. That electrode is then connected to the generator via a subcutaneous tunnel and then the unit includes three standard leads placed transvenously into the right side of the heart. One is in the right atrium for sensing and two are placed in the right ventricular for sensing and delivery of impulses. So again this the optimizer is the common system for this and the FDA did approve this back in March of 2019. And here are the reporting options. Again these are all category 3 as well so just depending on what you have supported in your documentation whether it's the initial insertion or replacement or removal or if they relocate that pocket you have a reporting option for that as well. All right so we covered the traditional and subcutaneous defibrillator systems but back in 2020 we had a new system added the extravascular ICD system. This system was designed to deliver defibrillation and pacing therapy in the same package as the traditional defibrillator but the lead is placed outside the heart in the veins. So you can kind of see what the different options and how they look. This is our traditional ICD. This is that subcutaneous where they tunnel that lead and this is that extravascular ICD right there. Again these are also category 3 so just depending on what you have supported whether it's that initial repositioning or removal you know just depending. The device evaluations we'll cover in the next EP series so we'll go through all that in detail with all of our different options of our monitoring services. All right so now we're going to cover some of the Medicare policies that we see and we're going to focus on the traditional pacemaker and traditional defibrillator systems today. So we'll start with that pacemaker system first. So here's the policy number the NCD 20.8.3. If you're dealing with Medicare you're going to want to check with your local Medicare contractor. Most have put out LCDs local coverage determinations and sometimes they put in a little bit more detail than what the national coverage determination may have. They all do look pretty similar to one another though so shouldn't be too much of a difference from what I'll cover with you from the national coverage determination. So the coverage states in the policy that it has to be documented non-reversible symptomatic bradycardia that's due to sinus node dysfunction or it could be due to a second degree or third degree AV block. And then of course there's other payable covered indications but for each local Medicare contractor though like I said they're going to have their own policy. Most do list what is nationally non-covered and what is covered. So here you can see these are some of the nationally non-covered indications and most of what falls under here is patients that are asymptomatic. Again continuing that whether they have syncope but they don't know the cause if they have bradycardia only documented during sleep you know any kind of blocks where they're not really having any symptoms otherwise they could fall under a nationally non-covered. But if they are covered under the policy the initial implants for the pacemakers so this policy only applies to the 332 0607 or 08. If they're having a battery change out and no lead procedures involved then you don't have to worry about a modifier for those. But for your initial implant where they're putting in a new generator with right-sided lead again you're going to look at these modifiers depending on what is supported for that patient. If they are meeting the policy you're going to pin that KX modifier. SC modifier can sometimes be supported if your KX is not supported. We'll kind of talk through those as we go through the policy. And then there's GA and GZ modifiers to the claim just depending on the ABN status. This is when the service is not expected to be covered under the policy. But you know depending on whether or not you got an ABN status signed by the patient or not you would append the appropriate modifier. So now just cover what is covered. So Medicare has done these in groups. So we'll start with group one. And again check with your local policy to see what they have out there regarding these implants. But remember KX modifier applies to 332 0607 or 08. And what you what it's telling the carrier is that the requirements specified in the policy have been met. So that's what the KX modifier means. So in group one these apply to our AB blocks. So you have you know complete AB block which is you know the complete sometimes you may see third degree. And then you have you know second degree you have first degree AB block sinus node dysfunction or if they have like a congenital heart block. So those fall under group one. Additional group two. So these are additional payable but these fall under group two. And this is them listing out those covered diagnoses. And this is actually what's in the policy. So they actually list out the diagnosis codes itself. So if you have an AB block and maybe it's just not specified. Now most times you should be able to find a specified AB block because the EP provider is going to be you know seeing that patient and addressing it. There are rare times though where maybe the patient's not stable they're brought urgently and they have the system put in. So you know that there there are rare times where I have seen I just don't I cannot find in the patient's chart the specific type of AB block that they have. You know you can always query your provider too if it's not specified. I do recommend that as well. But again if it's not specified and you can't get any further details the unspecified will pay as long as they're symptomatic. First degree AB block also symptomatic. Left bundle branch, right bundle branch. If they have bifascular, trifascular those types of things those are all covered under the group two under the policy. Additional group two there's lots under group two that's listed. So you have your blocks, your AB blocks, your bundle branch blocks and then you have additional arrhythmias that could be supported under the policy. So whether they have an SDT or an AFib or flutter and then they're symptomatic and then due to medical therapy that they could be put on a medication that's now causing them to come out of that arrhythmia when they're on the medication but now it's causing them to become bradycardia. So that's where they could fall under the group two policy here. Most common that I see is patients with AFib but you can see the policy is very specific. They list out the AFib codes that are payable and then it also states that the patient's having symptomatic bradycardia due to the necessary medical therapy. So this could be whatever drug they're on it's taking them out of the AFib but now they have bradycardia because of that medication. Now medicare was kind enough to list out the AFib codes they will cover. So you can see here proximal is not an option. Chronic or permanent is not an option. So you have persistent whether it's persistent or long-standing persistent and then you have unspecified. So they'll pay unspecified but not proximal. So again unfortunately it's medicare here so if you have a I do have them sometimes where the patient clearly has proximal AFib and but they have the bradycardia. So I mean you have to code what you have. So I don't know success rate with those with the pairs if you are having to code proximal AFib with the bradycardia. Sometimes they may say the patient has tacky brady syndrome. So that is actually crosswalk to the sick sinus syndrome and then you would code the type of arrhythmia that you know they're having an issue with. So just depending on your documentation but just remember group two with the arrhythmias is going to be whatever type of arrhythmia and then they're you know having additional symptoms that are now causing them to go bradycardia because of that medical therapy. Additional group two this is hypersensitive carotid sinus syndrome. I have not I've maybe coded this code in my over 15 years in cardiology maybe once or twice so not as common that I see it but you know I have seen it. So if they have and they're supported under this G90.01 then that still does fall under the supported KX under group two. So SC modifier when would you maybe append that instead of a KX? So most commonly is when they're having a CRT device put in. So maybe the patient has you know not ischemic cardiomyopathy. They have bradycardia and they also have congestive heart failure. The patient opts to have a pacemaker instead of a defibrillator because sometimes the patient will request to have a pacemaker only and that could just be due the the potential of the defibrillator to shock a patient sometimes is not appealing to a patient so they may opt to just do the pacemaker system only. So if you are not meeting a KX modifier requirement in the policy for the initial implant but they're getting that cardiac resynchronization therapy with the addition of that LV lead that this would be an example of when you may report an SC modifier on that initial implant because they're not meeting the KX but they're still falling under the supported policy with the SC modifier. You don't report it it says generator or pacemaker or generator replacements again if you're just reporting a straight generator change you don't have to worry about a modifier. This would be maybe where they're also getting a right-sided lead procedure involved and they're not meeting the KX policy requirements is again where you might report an SC for that. All right so now we're going to cover our defibrillator national coverage determinations. So this is the policy the 20.4 from Medicare. This has had several revisions since it was created. It's been effective for a very long time I think they did some updates on it so if you remember if you've been coding in cardiology for many years you remember way back in the day the defibrillator systems used to require that Q0 modifier but that policy went away several years ago so you do not no longer need to append the Q0 modifier to the defibrillator implants and there are six national covered indications in the policy for the implant and we'll kind of talk through each of them. The most commons that I see are definitely number one and then the next page will cover what I commonly see too. So nationally covered indication number one is when a patient has a history of VTAC or cardiac arrest due to ventricular fibrillation. So sometimes I may see the patients coming in the hospital they have an active STEMI they go into VFib cardiac arrest and after the interventional cardiologist you know gets the patient stabilized with a STEN or whatever they end up having to do interventional-wise EP may see them and also place a defibrillator because they went into that VFib arrest. So that's a common one I see for the initial or if they just have ventricular tachycardia and you know the provider hasn't been able to get them stable via an ablation procedure or medication therapy so they may opt to put in a defibrillator for those as well. Covered indication number two is a patient that had a prior MI and their measured left ventricular ejection fraction is less than that 30 percent and then they further clarify the patients must not have had New York heart associated classification stage four heart failure or had CABG or intervention or angioplasty within the past three months or had that MI within the past 40 days. So again it's just going to depend on what you have documented. Again like I said out of the two here most common that I see would be indication number one. Indications three and four are also very common. These are pretty similar except depending on the type of cardiomyopathy they have. So number three is if they have ischemic dilated cardiomyopathy. Number four is non-ischemic dilated cardiomyopathy. If you're reporting cardiomyopathy as you're in for your initial implant these do require a secondary diagnosis of congestive heart failure. So we will cover what that looks like on the next slide. So the policy does specify the type of heart failure that is supported. So it would have to be systolic or a combination of that systolic and diastolic. You will notice that it does not cover unspecified at all. So if you have an I-5020 that is not covered under the policy and your claim will most likely deny. So you would have to have the specific type of heart failure and again it would either be systolic or the combination with both the systolic and diastolic. And then nationally covered indications five and six. So I don't see five too often. This is patients that have documented familial or genetic disorders where they may have a high risk of life threatening you know tachyarrhythmia is like that v-tach or v-fib or they have that hypertrophic cardiomyopathy. And then number six is patients with an existing device where they are having the generator maybe at the end of its life and they're just getting the battery changed out. Again with this policy you don't append any modifiers anymore. Back in the day we used to but this is just showing what is covered under the policy when you are reporting those implants. And then additionally on top of the six covered indications the policy does say the patient must be clinically stable so they can't be an active shock you know from that standpoint. The left ventricular ejection fraction must be measured and documented either by an echocardiogram, any type of nuclear imaging, cardiac MRI, those types of things or it could be a catheter based angiography. And then also the policy states patients must not have had significant irreversible brain damage, any disease other than cardiac disease for example cancer, renal failure, where their likelihood of survival is less than a year, and then any SVT tachycardia that has a poorly controlled ventricular rate. So again that's just additional details that are listed in the national coverage determination there. All right so we are going to cover some case examples now. I believe I have six total to cover with you today so we'll go through these in detail. So with the first case this is a the wish list states implantable implantation of a dual chamber permanent pacemaker. Indications are symptomatic six sinus syndrome. And then I kind of made the coloring a little different just to point out keywords here. So you know as all procedures start out they get their consent. You know if there's any type of anesthesia usually it's listed somewhere within the report. Some of these cases today will have moderate sedation, some will be general anesthesia. This case wasn't as specific with that so obviously we're not going to cover. It just talks about local anesthetic was provided to numb the area. But they do state right here when you're doing an initial implant you definitely want to see that a pocket was created. So we do see that here pacemaker pocket was created. Then they go on and say that they introduced the leads and they have both an atrial and ventricular lead as they were introduced. When they're placing leads sometimes they'll do a venogram to help do that lead placement like I said that if it's done to help place the lead it's not diagnostic it's just done as road mapping. Once they get to the lead to the chamber of the heart they'll typically do lots of testing, taking measurements and all that stuff to find a suitable spot to place that lead. So here you know down here they list the actual lead medtronic system and they say where they placed it in the right atrial appendage. Then they give all the measurements, thresholds, all that stuff where they found it was satisfactory. Then next page here we have our right ventricular lead details with the medtronic system. Then they get their measurements and satisfactory testing. Then it states both of the leads were secured. So that's typical again when you're doing an initial implant. They then place the leads and connect it to the generator and then they put everything within that pocket and close the patient up. So this is a pretty standard straightforward initial implant of a dual chamber pacemaker. So our final coding here would be our 33208 with our KX modifier for our symptomatic sixth sinus syndrome and then the I495 for the diagnoses. All right case example number two this is an upgrade to a biventricular defibrillator from a dual chamber pacemaker. So the patient's getting an upgrade of their system. Wishlist it talks about insertion of a pacing electrode in the cardiac venous system for left ventricular pacing at the time of a generator change and what they mean by that is because they're upgrading the system they're going to take the the pacemaker generator out because they're upgrading it to a defibrillator system. So that's what they're talking about there. Our indications is dilated cardiomyopathy, chronic systolic heart failure, second degree AV block and then they also have high RV pacing thresholds. So here you can see we had anesthesiology involved so there will be no moderate sedation here. Again got the consent and all that wonderful stuff numbing the chest. They're going to do an incision over the old scar where the pacemaker generator is located and they after they open up the patient they pull out that existing pacemaker generator. A left upper extremity venogram was done which showed a patent auxiliary vein. So this right here is what I'm talking about with the venograms. This was not done for diagnostic purposes it was done to help aid in the lead placement. So our venogram here is definitely not going to be billable. All right access to the left auxiliary vein was obtained using the technique guide wires replaced fluoroscopy was done that's not separately billable as well and it was advanced through the the inferior vena cava. They then get the sheath placed and an RV lead was advanced into the right ventricular apex. Now remember we're getting an upgrade of a pacemaker to a defibrillator so pacemaker to a defibrillator. So typically when that's involved the patient's right ventricular lead for a pacemaker does not have the same capabilities as a right ventricular defibrillator lead. So most times when you see a pacemaker upgraded to a defibrillator they're almost 99% of the time they're going to be placing a new RV lead because it's different from the RV pacing lead. So that's what is happening here with this case they're placing that new RV ICD lead and they're going to place it in the RV apex. They're now doing testing and getting adequate measurements and stuff and then they're going to suture that lead down so it stays secured. Then it states another peel away sheath was advanced over the wire a left bundle sheath was advanced into the right ventricle. A lead was positioned in the right ventricular again they do testing get adequate measurements. They're near that area of the HIS bundle so this is telling us that they're in the septum. Once seen the lead was deployed and manually screwed into the ventricular septum until left bundle capture was noted. So now we have the addition of a new right ventricular ICD lead which was placed in the right ventricular apex and we have a new addition of a left bundle branch lead which was placed in our RV septum. And then they suture that down down here and then they attach those leads to the exit to a new ICD pulse generator. So remember we had a pacemaker generator come out and now the patient's going to leave with a defibrillator system. Again this is just testing you know talking about fluoroscopy all that stuff that's not separately billable. This is details of the device. So you can see the old RV pacemaker lead was capped. It didn't detail that in our body of our report, but there's nothing billable for it anyways. But that is still pretty standard. We had our new RV lead that was placed. They didn't really give us details of the right atrial lead, but they do have one in place. They call the left bundle branch lead an LV lead, but it's not, it was placed in the RV septum, but that's what they call it. So what we have here is an upgrade of two of, they call it a biventricular defibrillator system with the addition of that left bundle branch lead. And they pin in parentheses, it was done in place of a coronary sinus lead. So here they're telling us they did not do a coronary sinus LV lead placement. And then they had the addition of the new RV lead, and then the old RV lead was capped. So what we end up for coding here is we have the 3, 3, 2, 3, 3, which was removal of that pacemaker generator. And then we have a 3, 3, 2, 4, 9. And here with the definition and how, this is how the code is listed in the CPT book. It's insertion or replacement of a defibrillator system with transvenous leads. So you see here this S in parentheses is important, and it's a single or dual chamber. Now we had two leads placed, but they were both placed in the RV and they had the existing RA. So this is what CPT coding wise we end up with because we're coding to the placement of the leads. And then our diagnosis would be the dilated cardiomyopathy, our chronic systolic heart failure, our AV block, and then our high RV pacing thresholds that was documented. All right, case number three, this is a dual chamber pacemaker upgrade to a biventricular pacemaker system. So here in our wishlist, it says upgrade to bivy pacemaker implantation with the addition of a new LV lead. And then they're going to be doing a generator change as well. And then any programming and all that is included. Coronary sinus venograms in our wishlist. Again, if it's done to help aid in placement of that lead, then we will not be billing for that. And then it specifies that sedation was done by the anesthesiology team. Patient in our indications with a dual chamber pacemaker for sinus node dysfunction back in 2004. They did have a generator change back in 2014. They do have that high percentage RV pacing with chronic systolic heart failure. And you can see over the various years of testing, their LV EF went from 55 to 45 to now down to 35%. So that's showing the systolic heart failure. And then they're presenting for that upgrade. So again, starting off after they get consent, the venogram was performed prior to the procedure that shows the venous anatomy is patent. So this was not done for a diagnostic reason. It was done to help lead our new leads. And then down here, it's just prepping and draping and doing a local anesthetic to the skin where the pocket is. So that's what we got here. And then to the next page, they talk about the pocket again, and then they go straight into placing that coronary sinus LV leads. So they do a coronary sinus venogram. It says it was done with good visualization with a lower posterior lateral branch. The lead was placed. So again, this venogram was done to help place that lead as well. The lead was placed in that lower posterior lateral branch and then the lead was tested and functioning well. So therefore it was sutured into place. The old generator and the existing leads were freed and the generator was removed from that pocket. The leads were removed from the header pins and cleaned. Typically when they're doing an upgrade like this, they'll still test the existing leads just to make sure they're still testing with adequate thresholds and all that stuff. And then they'll do any cleaning that's needed for that. That's all part of your procedure though. And then at the end here, they cleaned out the existing pocket and the device was attached to the leads after cleaning. And then it was placed within that pocket and then closed up. So for this one, again, here is all of our device details. And this is pretty standard when you're coding for a device procedure. They're always gonna list the manufacturer, the model number, the serial numbers, all that detail usually is within your operative report. So you can see here, they did end up with the coronary sinus sleeve and then they already had that dual chamber system in place. Additional measurements and testing, all this programming, all that stuff is included with your placement and our conclusions are a successful upgrade from that dual chamber to a Bi-V system. So what we end up coding here because there was no right-sided lead procedure needed, the patient left the cath lab with three leads in place. So they have a multi-chamber system now. So 3,3,2,2,9 for your generator change of that pacemaker and then your additional add-on code for the LV lead that was placed in the coronary sinus with the 3,3,2,2,5. And then we have six sinus syndrome. They have that chronic systolic heart failure and then the high RV pacing thresholds again. And we don't need a KX or nothing like that with our generator only change. Again, if they would have done a right-sided lead with this and maybe the right ventricular lead wasn't functioning anymore and they replaced it, then the coding obviously would change there and you would report the 3,3,2,0,7 if they placed a new RV lead with your new generator and then your 3,3,2,2,5. So coding can vary obviously just depending. So keep in mind when you have a right-sided lead involvement with the generator change, from there you're gonna code what was removed and what was implanted. But here we just had a generator with the addition of that LV lead. Case example number four, this is pretty standard, straightforward documentation of that loop implant, the implantable loop recorder. This patient has a history of syncope. So again, that's a standard reason that they do these. Like I said earlier, a lot of times another standard reason is if they have that CVA and they're gonna monitor to see if they have underlying AFib. As you know, AFib can cause the patients to have strokes if not treated. So a lot of times when we do see stroke patients and they don't have any history of that, they do opt to go ahead and place this loop implant. So with these, they create a small subcutaneous pocket. They then insert the monitor within that little pocket and then they just close the patient up. Pretty straightforward procedure. No global period associated with these, 3, 3, 2, 8, 5, and then your diagnosis is gonna be your syncope. All right, case example number five. This is an existing ICD system with an addition of a left bundle branch lead. Our indications are ischemic cardiomyopathy and chronic HFREF. So if you look in your diagnosis book, cause I do see these heart failure documented like this a lot now. If you go to the systolic heart failure in your book itself, it will reference this HFREF. What it means is heart failure reduced EF. So that's the systolic heart failure if you see an R. And then they also have documented ventricular tachycardia. So again, standard documentation here, patient's prepped and draped. Gonna do local anesthetic. They are going to put a needle through the axillary vein and advance it. Incision was made close to the scar of the previous incision. Dissection was done to extend the defibrillator pocket. The old generator was removed and the existing leads were disconnected. The pocket was revised to accommodate the new device. So they're not moving the pocket, they're just revising it to accommodate the new generator they're gonna place. So this would not be a pocket relocation. The leads were tested and they were found to have adequate pacing and sensing threshold. So again, this is common when you have an existing system already involved. Now they're gonna go into placing that left bundle branch leads. So they say, talk about that his sheath was placed and advanced to the RV septum. The target left bundle branch pacing site was identified on the mid RV septum and the sheath and lead were advanced to this area. The lead was fixated in the RV septum and non-selective left bundle branch capture was achieved. After adequate pacing and sensing thresholds, the lead was then secured. The leads were then connected to a new pulse generator and then the pocket was cleaned up and closed. They did talk about moderate sedation with the intra-service time of 50 minutes. They give further details and talk about the trained independent observer that was monitoring the patient continuously. So they say this is a successful CRTD upgrade with the addition of that left bundle branch lead. So here's our implants with our generator, or this is our, yeah, our generators here. Here's the new addition of the left bundle branch lead. And then here we have, so we had a right-sided lead because we placed a left bundle branch in the RV septum. So we code for what was removed and what the patient had implanted. So removal of the existing generator for the defibrillator, 3, 3, 2, 4, 1. And then 3, 3, 2, 4, 9 is gonna support our new generator and our new left bundle branch in the RV septum. And then of course our moderate sedation. This patient has ischemic cardiomyopathy, the chronic systolic heart failure, and then that ventricular tachycardia. All right, so this is our last case example. So this was an ICD downgrade to a pacemaker system. So earlier in the presentation, I had mentioned this one. So this one, the patient has an existing defibrillator and they want to have it downgraded to a pacemaker system. And when I actually looked at the, cause these are all real case examples. When I looked at this case, cause it's not common that you see it downgraded like this. This patient has end-stage Parkinson's disease and they have severe frailty. So they are getting to the end of life, unfortunately. They did not want to have the system shock them anymore or the potential to have it shocked. So that's why they're having the system changed out. So again, they're gonna open up the patient, take out the existing defibrillator generator that's in place. You can see we have our moderate sedation documented 45 minutes. They detail the sedation here and they talk about the independent operator. Here's where they're going to open that old incision and pocket, and they're gonna take out that defibrillator system here. The generator was removed. They then do testing on the leads and such. So they have the RV and the atrial lead that they do testing on. And then they attach to that newly pacemaker pulse generator pacemaker pulse generator. And then they close the patient. So this was really just truly where they took out the defibrillator generator and put in a pacemaker generator. So for this one, we're gonna code for the removal of that defibrillator generator, the 33241. And then we code for the insertion of a dual chamber pacemaker generator because it was attached to both existing leads. And then of course our moderate sedation. So again, this patient does have six sinus syndrome. They also have the ischemic cardiomyopathy. Their generator was at end of life, but they opted to have it downgraded to a pacemaker. And then of course the Parkinson's disease with the physical debility that they have. All right, and then this is just our disclaimer stating that this was all for informational purposes only and does not constitute legal reimbursement, coding, business or other advice. We do always recommend you check with your local Medicare contractors and obviously your local other payers that you deal with and consult with your practice's legal counsel for any coding and reimbursement advice. And then everything we covered today was in our, this is a CPT disclaimer. So everything came from the American Medical Association. And then this brings us to our Q&A. So I will get that pulled up real quick and go through. And again, there are several questions here. So I know I won't have time to get through all of them, but we will compile the questions, like I said, and it will be put in a document on our website. So you will have options once you log into your MedAx SEME Academy. Give me probably about two weeks to get the Q&A document uploaded to our site though. All right. Going through questions real quick. If you just bear with me a minute. Physician performed implantation of a biventricular defibrillator and the provider insists on adding the 3,3,2,2,5 for implanting that left bumble branch lead. But the coder states coronary sinus was not entered. So 3,3,2,2,5 is not built. That is correct. And I've actually talked with several EP providers because when these first started becoming more popular and if you code device implants now, you see a lot of left bumble branch leads being done now. So I picked one specific provider's brain one day because he had called me asking me questions. So I was like, well, while I got you on the phone, let me pick your brain too. So I asked him about these. I was like, where, like with the LV lead placement, can it ever classify as the LV lead placement? Is it placed in the cardiac venous system? Because that's the definition of the LV lead, essentially the 3,3,2,4 through 2,5. It states cardiac venous for left ventricular pacing. So because the left bumble branch is in the septum and he told me that these leads are not made to stretch how they're being stretched. And he predicted that a lot of these leads are probably going to fracture or dislodge. And if you code a lot of these devices, you might be seeing an increase of that too, which I can personally say that I do, you know, and I don't know if it's because the leads are being stretched too far or whatever, but they're not made to stretch to the LV is the point. So they're not placed in the cardiac venous system and they're definitely not placed in the LV. So I do think there is a need for a new code to be created. I can't tell you if that's even on the AMA's radar to do. So again, right now current guidance is to code to where the lead was placed. And as you saw in the case examples we had today, those were real case examples. So that is how the provider's documenting these. They are placed in the RV septum, at least for the cases we looked at. So that would be an RV lead here. So again, yes, you would not, a left bundle branch lead is not the same as the cardiac venous for the left ventricular lead placement. Okay. So I didn't cover this today, but I do see it. So I will read the question. So it says our physicians are wanting to bill 37241 or 37242 when they're placing bridge occlusion balloons. And they're doing it as a preventative though. And this is common. So sometimes if the patient's having a lead procedure done or whatever the situation may be, sometimes they place these bridge occlusion balloons, but again, they're doing it as a preventative just in case something might happen or go wrong, then they can stop whatever injury occurred. Those cannot be coded. They're part of the primary procedure you're doing it because you're not doing it to treat a condition per se. You're not putting that balloon in the tree. You're doing it as a preventative just in case something happens. So you would not bill for those codes because you're not doing it as how the codes are defined. So no, I would not recommend reporting those codes. Let's see. Somebody said, would you code 33208 and 33216 if you are doing a left bundle branch lead with a dual chamber system? So no, you would not. If you look at how the CPT codes are defined, they state lead and then they put plural in parentheses. So it can include more than one lead to a chamber. So, and it's like that, like say you're looking at an RV pacemaker code, the 33207. It says right ventricular lead and then says leads in parentheses. So if you're getting a right ventricular lead and a left bundle branch lead to the RV septum, that would account for both leads. Now, if the procedure for whatever reason, maybe took longer than the provider expected, or was, you know, he had difficulties or whatever the situation, you could possibly have the option of reporting the modifier 22 for increased services. But again, if it's just a pretty standard procedure, no difficulties, then I would just code it as the lead placements itself. So if you had a dual chamber system put in and the addition of a left bundle branch lead, so they had a right atrial, right ventricular, left bundle, and it's a pacemaker, it would just be a 33208. Let's see. If a patient has EP study with ablation followed by a defibrillator implant, can you also bill for DFT testing or would it bundle? That one, I don't know off the top of my head. It's not a common scenario. I see, I would recommend you just check NCCI edits if they both are separately reportable. And, you know, if they do edit and a modifier is allowed, you know, just make sure the documentation supports. Definitely not a common occurrence that I would see with the defibrillator implant though. Now, sometimes with the defibrillator implant, I could give you this scenario. Sometimes they might do a component EP study where they're only looking at the ventricular portion of it where they're doing the RV pace and recording. So you can report those component codes. Typically when that happens, I see the partial EP study or the component EP study done first. And if they obviously induce VTAC during that study, they're gonna stop immediately and then they're gonna do the implant with the defibrillator. So again, it's just gonna vary what you have documented. Now, the component EP study with the RV, when you're looking at a defibrillator implant, those do bundle or there is an edit, but you can override it with a modifier. So if you do that component study first, obviously the physician's doing it for diagnostic reasons. If they do induce that arrhythmia, then they're deciding in that moment, they're gonna go ahead and do that implant. That would be a scenario where you would report, you know, your modifier to override the edit because it was done for diagnostic reasons. Now to say whether or not the DFT testing, if they did do it at the same session, again, I don't know that off the top of my head, but just I recommend you check the NCCI edits and see if they bundle. All right, we are almost at time. So I will see if I can find one more question here. Are there any codes as of yet that can be used when they use the device for that cardio version? There is not. So again, if they're doing the pacemaker, you could potentially report that. I don't know the code off the top of my head, but it was in the slide deck, the 9,000 code. Sometimes they'll pace the patient, you know, out of the arrhythmia with the pacemaker itself. It's not really cardioverting them, they're pacing the patient out. If they do a cardioversion, and I do see these sometimes done through the defibrillator device, especially, that's, it's unlisted, unfortunately. There's no CPT code for those. All right, well, we are at time. And like I said, I will compile the remaining questions and the ones I answered live too, we'll add to the Q&A document and we will get these uploaded in the next couple of weeks on our website. Definitely stay tuned for the next series. I'm planning to do that in the summer and it will cover the cardiac EP monitoring services. So all your in-person remote device checks will also cover, you know, the standard, you know, Xeo patches, Holter monitors, all those different monitoring services we'll cover in that presentation later in the summer. I do appreciate everybody's time today and thank you for joining us and hope you found value in all the information provided. Have a great day.

coding guidelines

EP device procedures

Jamie Quimby

MedAxiom

new device implants

generator changes

lead procedures

DFT testing

temporary pacemakers

loop recorders

wireless cardiac stimulation systems

accurate documentation

Medicare policies