Coding for Procedures on Pacemakers and Defibrillators in ICD-10-PCS

ICD-10-PCS coding for the insertion, replacement and upgrades of pacemakers and defibrillators can seem a bit overwhelming. However, knowing a few basics about the devices, applying some coding tips and taking the process one step at a time will make code selection simple and easy in no time.

Pacemakers vs. Defibrillators

Pacemakers

A pacemaker sends an electrical signal to the heart muscle to treat arrhythmias, such as brady or tachycardia. A pacemaker only activates when it is needed; it does not continuously send electrical impulses to the patient’s heart.

All pacemakers have two main components. A generator which contains the battery and electronic components, and an insulated wire called a lead. The lead carries electrical impulses from the pacemaker to the heart muscle. Depending on the type and cause of the patient’s arrhythmia, the pacemaker may have one, two or three leads. Leads are implanted in the atria or the ventricles.

There are four main types of pacemakers:

• Single chamber - One lead is inserted into an atrium OR ventricle. Atrial leads are, most commonly found in patients with sinus node disease or in patients who do not have heart block. Ventricular leads are most commonly found in patients with atrial fibrillation.
• Dual chamber - Two leads are placed, one in the right atrium, one in the right ventricle. This is most commonly seen in patients with a heart block.
• Biventricular/CRT-P – With these devices, the patient always has a right ventricular lead and a left ventricular lead. Biventricular pacemakers are also known as a CRT (cardiac resynchronization therapy) devices. CRT is used to treat patients with advanced heart failure by helping the heartbeat in a more balanced way. Sometimes the electrical impulses that control the heart muscle contraction and relaxation do not travel rapidly and evenly through the heart. A CRT device differs from typical pacemakers that only control heart rate and pace the right ventricle. The CRT device not only functions as a pacemaker, but it also resynchronizes contractions of the two ventricles by pacing them both simultaneously which improves the overall efficiency of the heart. A CRT device has at least two ventricular leads but it may also have a third lead in the right atrium.
• Intracardiac Leadless Single/Dual Chamber Pacemaker – A ventricular leadless pacemaker is directly implanted into the right ventricle and an atrial leadless pacemaker is directly implanted into the right atrium to provide dual chamber pacing therapy. The system does not require the separate cardiac leads and pulse generator components of a traditional pacemaker. These pacemakers are usually placed to treat bradycardia. Under fluoroscopic guidance one leadless pacemaker is inserted through the inferior vena cava into the right atrium and the other leadless pacemaker is advanced through the tricuspid valve for placement into the right ventricle. Both devices may be implanted during a single operative episode, or an existing single chamber leadless pacemaker device in the right ventricle may be upgraded to a dual-chamber pacing system when a leadless pacemaker is inserted into the right atrium.

Defibrillators

Another device which can be implanted to correct arrhythmias is a defibrillator, commonly referred to as an ICD (implantable cardioverter defibrillator) or an AICD (automated implantable cardioverter defibrillator). An ICD is a device used to help prevent death from a cardiac arrest. An ICD will send a shock to the heart to correct life-threatening rhythm disturbances from the lower chambers of the heart. This device has a built in pacemaker that can prevent the heart from beating too slow or slow the heart if the rhythm is too fast. ICDs are more effective in patients who have a history or who are at high risk of sudden cardiac arrest.

Coding Tips

• With the exception of leadless pacemakers, the insertion of pacemakers and defibrillators requires the assignment of one code for insertion of the generator/battery portion of the device and one to three codes for insertion of the leads.
• Removal of a previously implanted device with replacement by a completely new device requires reporting a code for removal of the old device and a code for insertion of the new device.
• The applicable ICD-10-PCS body part values for devices in a single anatomic site are different depending on the root operation assigned to report the objective of the procedure.
• The codes for lead and generator insertion are more specific. The codes for removal and/or revision of generators or leads are more generic.

Steps to building an ICD-10-PCS Code

Knowledge about the structure and function of pacemakers and defibrillators combined with expertise in ICD-10-PCS coding are used when selecting character values to build codes for appropriate reporting of procedures involving these devices. The first step to getting a correct code is to identify the right ICD-10-PCS code table to build a code from. Selecting the right table is dependent on selecting the correct option for the ICD-10-PCS section, body system and root operation.

• ICD-10-PCS Section
  • Medical and Surgical Section – Most procedures performed on pacemakers/defibrillators will be coded from the Medical and Surgical section.
  • New Technology Section – Insertion only of dual chamber, leadless pacemakers is coded from the New Technology section. Removal or revision of these devices is coded from the Medical and Surgical section.
• Body System
  • Heart and Great Vessels – Procedures that involve pacemaker leads, most defibrillator leads and single chamber leadless pacemakers are coded from the Heart and Great Vessels body system in the Medical and Surgical section of ICD-10-PCS.
  • Skin and Subcutaneous Tissue – Pulse generators are usually inserted into a pocket made in the wall of the chest. This procedure is coded in the Skin and Subcutaneous body system. Some defibrillator leads may be inserted subcutaneously. Procedures on these leads are also coded from the Skin and Subcutaneous Tissue body system.
  • Cardiovascular System – Insertion of a dual chamber leadless pacemaker is coded from the Cardiovascular System body system in the New Technology section of ICD-10-PCS.
• Root Operation
  There are three main root operations that represent the objective of procedures involving pacemakers and defibrillators: Insertion, Removal and Revision.
  • Insertion – The root operation Insertion is used for procedures involving the initial placement of pacemaker or defibrillator components or when a previous device has been removed and is being replaced with a completely new device.
  • Removal – When a previously implanted device is being removed and replaced with a completely new device, a code with the root operation Removal is assigned for the removal procedure.
  • Revision - When a patient needs attention to a previously placed device, such as repositioning of a lead or generator, and a repair or reposition procedure is performed and the same device is put back into the patient, this is coded with the root operation Revision. Revision does not include taking out the entire device and putting in an entirely new device in its place. This is coded as removal and insertion.

Once the correct code table is located, the coder must review the character value options for the remaining four characters to finish building a code: body part, approach, device and qualifier. 

• Body Part
  The body part character value options for the root operation insertion are different than the character value options for the root operations removal and revision.
  • Right and left atria/ventricles – When coding for insertion of leads or single chamber leadless pacemakers, there are specific body part options for atria vs. ventricle and right vs. left.
  • Heart – Procedures for removal or revision of leads or single chamber leadless pacemakers do not have specific body part options for the atrium/ventricle where the device has been implanted. The code tables with these root operations have only a single body part character value option of “Heart” for these procedures.
  • Subcutaneous Tissue and Fascia, Chest – Procedures for insertion of device generators or subcutaneous defibrillator leads are coded with the body part character value of Subcutaneous Tissue and Fascia, Chest.
  • Subcutaneous Tissue and Fascia, Trunk – Removal or revision procedures on device generators or subcutaneous defibrillator leads are coded with a less specific body part character value option of Subcutaneous Tissue and Fascia, Trunk.
• Approach
  Most procedures on pacemakers or defibrillators will be performed through an open or a percutaneous approach.
  • Open – Device generators and some defibrillator leads are implanted in the subcutaneous tissue of the chest. Procedures to insert, remove or revise these device components require incision to reach the site of the procedure. These procedures are reported with an open approach.
  • Percutaneous – Insertion of leads and single/dual chamber leadless pacemakers is generally performed over a guidewire via catheterization of a vein. This type of approach, where the operative site is not directly visualized, meets the ICD-10-PCS definition of a percutaneous approach.
• Device
  There are lots of options for pacemaker/defibrillator leads and generator devices. This is the character value that really communicates the specific type of procedure being performed. Careful review of the operative note and implant records is needed to ensure the right type of device is being reported.
  • Leads - ICD-10-PCS has three device options for procedures where leads are being inserted:
    • Pacemaker
    • Defibrillator
    • Subcutaneous Defibrillator
    ICD-10-PCS had one device option for procedures where leads are being removed or revised:
    • Cardiac Lead
  • Generator Devices – ICD-10-PCS has seven device options for procedures where generator devices are being inserted:
    • Intracardiac Pacemaker (single chamber)
    • Pacemaker, Single Chamber
    • Pacemaker, Single Chamber, Rate Responsive
    • Pacemaker, Dual Chamber
    • Cardiac Resynchronization Pacemaker Generator
    • Defibrillator Generator
    • Cardiac Resynchronization Defibrillator Generator
    ICD-10-PCS has one option for procedures where generator devices, including dual chamber leadless pacemakers are being removed:
    • Cardiac Rhythm Related Device
• Qualifier
  • No Qualifier – There are no qualifiers applicable to most of the procedures performed on pacemaker or defibrillator devices.
  • New Technology Group 9 – New technology codes for insertion of dual chamber leadless pacemakers have a qualifier character value of “9” to report New Technology Group 9

The table below summarizes the information presented and provides the character values assigned for each type of procedure at each step of code building.

Click here for a downloadable PDF of this step by step coding of pacemaker and defibrillator procedures table. 

For a deeper dive into pacemaker and defibrillator coding, take our HIALearn course Pacemaker Procedure Coding in ICD-10-PCS.

References

FY 2025 ICD-10-PCS

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The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.