Defibrillator Coding in ICD-10-PCS - Coding Correct Lead Insertions and Generator

HIA has found on Quality reviews that coders may be forgetting or missing coding all of the appropriate leads inserted for the correct device, along with the actual generator insertion. First, we will briefly discuss the differences.

Pacemaker

A pacemaker is a device that is designed to send an electrical signal to the heart muscle and helps to maintain a proper rhythm. A pacemaker only activates when it is needed; it does not continuously send electrical impulses the patient’s heart. All pacemakers have two main components. A small metal box (generator) which contains the battery and electronic components, and an insulated wire called a lead. The lead carries the electrical impulses from the pacemaker to the heart muscle. Depending on the patient’s condition, the pacemaker may have one or two leads which are attached. Single-chamber devices have a lead inserted into the atrium OR ventricle. For dual-chamber devices, two leads are placed, one in the right atrium, one in the right ventricle.

There are also new intracardiac leadless single and dual chamber devices that are now available in which the generator is part of the lead and there is not need for a battery to be placed in a separate pocket.

Defibrillator

Another device which can be implanted to correct arrhythmias is a defibrillator, commonly referred to as an ICD (implantable cardioverter defibrillator). An ICD is a bigger device than a pacemaker which continuously monitors your heart rhythm. This device is used to help prevent death from a cardiac arrest. An ICD will send a shock to the heart if a life-threatening rhythm disturbance occurs from the lower chambers of the heart. It can correct this rhythm. This device also can stimulate the heart like a pacemaker because it has a pacemaker built into it. It can help prevent the heart from beating too slow and can also help slow the heart if the rhythm is too fast. The primary difference between an ICD and a pacemaker is that pacemakers give low-energy electrical pulses to restore regular heart rhythm. An ICD, however, continually monitors the patient’s heart rhythm and can send low or high-energy electrical pulses or shocks to correct the arrhythmia. An ICD initially sends low-energy pulses to attempt restoring normal heart rhythm; however, when these low-energy shocks are ineffective, ICDs switch to high-energy pulses.

Defibrillator leads are typically placed in right atrium, right ventricle and coronary sinus or left ventricle.

Per AHA Coding Clinic First Quarter 2018, page 19, a lead that may be classified as a pacing lead, such as the CapSureFix Novus lead in a right atrium, if it is being connected to a defibrillator device it is coded to insertion of DEFIBRILLATOR lead. The fact that the lead is attached to a defibrillator takes precedence over the manufacturer’s classification of the device as a pacing lead.

Coding Error Sample

In the case below, the coder mistakenly coded “PACEMAKER” leads insertion instead of Defibrillator leads leading to a DRG change. See the details below of codes and documentation.

MS-DRG 245 AICD generator procedures R.W. 4.5314

to

MS-DRG 276 Cardiac defibrillator implant with MCC R.W. 6.2102

• 0JH609Z Insertion Card Rsync Defib Puls Gen in Chest Subcu/Fascia, Open
• 02H63KZ Insertion of Defibrillator Lead into Right Atrium, Percutaneous Approach
• 02HL3KZ Insertion of Defibrillator Lead into Left Ventricle, Percutaneous Approach
• 02HK3KZ Insertion of Defibrillator Lead into Right Ventricle, Percutaneous Approach
• 02583ZZ Destruction of Conduction Mechanism, Percutaneous Approach

The medical records document insertion of a Medtronic CRT-D system with three defibrillator leads on 02/23/2022. However, the procedure codes assigned report the insertion of a pacemaker leads which led to incorrect MS-DRG 245.

- Replace procedure code 02H63JZ Insertion of Pacemaker Lead into Right Atrium, Percutaneous Approach with 02H63KZ to report the defibrillator lead insertion into the right atrium

- Replace procedure code 02HL3JZ Insertion of Pacemaker Lead into Left Ventricle, Percutaneous Approach with 02HL3KZ to report the defibrillator lead insertion into the left ventricle

- Replace procedure code 02HK3JZ Insertion of Pacemaker Lead into Right Ventricle, Percutaneous Approach with 02HK3KZ to report the defibrillator lead insertion into the right ventricle

Operative Note

Medtronic CRT-D implantation

Unsuccessful AVN ablation via right femoral vein access with 8 mm nonirrigated ablation catheter.

Complications: No complications were associated with this study.

Procedure Details

This man has a history of acute on chronic systolic heart failure and reduced ejection fraction (I50.23). He has incessant SVT (I47.10) which we have been unable to control with ablation. He was recommended for AV node ablation and CRT-D implantation.

The patient was brought to the EP lab in a fasting state.

He was sterilely prepped and draped. He was sedated with IV fentanyl and Versed for total procedure time of 180 minutes.

We first accessed his right femoral vein and placed an 8 French sheath as planning for our AV node ablation.

We then numbed the skin and underlying tissue over the left deltopectoral groove and made an incision. We dissected to identify the cephalic vein which was accessed via direct cutdown. A single coil ICD lead was advanced to the RV apex. Sensing of R waves was 7 mV with an impedance of 500 Ohms and a capture threshold of 0.5 V. A pacing lead was advanced to the right atrial appendage. Sensing of P waves was 1.6 mV with an impedance of 700 Ohms and a capture threshold of 2 V. The lead was challenged and found to be in a stable position.

A left arm venogram was obtained. The subclavian vein was accessed a single time via direct puncture. A CS Worley sheath was advanced to the heart over a Terumo wire. The CS was cannulated with some challenge. We ended up accessing with an AL1 catheter. There was a valve and we were unable to advance our Worley sheath across. We ended up getting through with a 130 inner catheter. We found a lateral branch. We shot contrast that outlined this lateral branch as the only acceptable target. We accessed the lateral branch and advanced a quadripolar straight LV lead over a whisper wire out this branch. There was no phrenic stimulation. There was <2 V capture threshold on electrodes 1, 2, and 3. The inner sheath was slit. The outer sheath was split.

The leads were affixed to the underlying muscle by their suture collar with 2 sutures to the LV lead and a single suture to the RV and RA leads. A prepectoral pocket was made. The pocket was copiously irrigated with antibiotic solution and hemostasis was assured. Arista hemostatic powder was used due to therapeutic INR. The leads were attached to a Medtronic CRT-D. The device was placed in the pocket which was closed with 2 layers of running Vicryl suture and overlying Histoacryl glue.

We then addressed our attention to the AV node ablation. We advanced an 8 mm nonirrigated ablation catheter to the level of the His bundle. Ablation of the AV node proved challenging. We were unable to achieve AV block, partly due to inability to see signals, possibly related to prior AVNRT ablations. At this point I opted to end the case. With CRT pacing with short AV delay he is not sustaining SVT. For more successful AV node ablation and irrigated catheter may work versus a left sided his ablation. Sheath was pulled from the groin and manual pressure applied.

He tolerated the procedure well and there were no acute complications.

ICD

Icd Crt Cobalt Quad Mri Is4 Df4 - - Implanted

Inventory item: ICD CRT COBALT QUAD MRI IS4 DF4      Model/Cat number:

Serial number:                               Manufacturer: MEDTRONIC CRM

Device identifier:                           Device identifier type: GS1

Implant Date: 2/23/2023              Initial Device: Yes

Pacemaker Pocket Location:   Pre-pectoral

GUDID Information

Request status      Successful

Brand name:         Cobalt™ HF Quad CRT-D MRI SureScan™     Version/Model: DTPB2QQ

Company name: MEDTRONIC, INC.         MRI safety info as of 2/23/23: MR Conditional

Contains dry or latex rubber: No

GMDN P.T. name: Cardiac resynchronization therapy implantable defibrillator

As of 2/23/2023

Status: Implanted      Mode: DDD

Lower Rate: 60          Upper Rate: 120

VF Detect Rate: 207

Implant Ep Lead

Icd Lead Sprint Secure - - Implanted

Inventory item: ICD LEAD SPRINT SECURE      Model/Cat number:

Serial number:                                                    Manufacturer: MEDTRONIC CRM

Device identifier:                                                 Device identifier type: GS1

Date Implanted: 2/23/2023                               Fixation: Active

GUDID Information

Request status               Successful

Brand name:                  Sprint Quattro Secure S MRI™ SureScan™       Version/Model:

Company name: MEDTRONIC, INC.               MRI safety info as of 2/23/23: MR Conditional

Contains dry or latex rubber: No

GMDN P.T. name: Endocardial defibrillation lead

As of 2/23/2023

Status:      Implanted                Lead Position:  RV

Lead Insertion Location: Cephalic vein PSA Amplitude (mV): 8.9

PSA Pacing Impedance (ohms): 571          PSA Capture Threshold (V): 0.5

PSA Pulse Width (ms): 0.5

Ppm Lead Pacing Vent Bipolar Cp Nv - Implanted

Inventory item: PPM LEAD PACING VENT BIPOLAR CP NV             Model/Cat number:

Serial number:                  Manufacturer: MEDTRONIC CRM

Device identifier:               Device identifier type: GS1

Date Implanted: 2/23/2023           Fixation: Active

GUDID Information

Request status      Successful

Brand name:   CapSureFix Novus MRI™ SureScan™        Version/Model:

Company name: MEDTRONIC, INC.        MRI safety info as of 2/23/23:   MR Conditional

Contains dry or latex rubber: No

GMDN P.T. name: Endocardial pacing lead

As of 2/23/2023

Status:  Implanted           Lead Position: RA

Lead Insertion Location: Cephalic vein PSA Amplitude (mV): 1.6

PSA Pacing Impedance (ohms): 695           PSA Capture Threshold (V): 2.3

PSA Pulse Width (ms): 0.5

Lv Lead Attain Performa 4398 78cm - Squb529443v - Log420210 - Implanted

Inventory item: LV LEAD ATTAIN PERFORMA 4398 78CM     Model/Cat number:

Serial number:               Manufacturer: MEDTRONIC CRM

Device identifier:           Device identifier type: GS1

Date Implanted: 2/23/2023

GUDID Information

Request status Successful

Brand name: Attain Performa™ Straight MRI SureScan™      Version/Model: 439878

Company name: MEDTRONIC, INC.       MRI safety info as of 2/23/23: MR Conditional

Contains dry or latex rubber: No

GMDN P.T. name: Endocardial pacing lead

As of 2/23/2023

Status:  Implanted           Lead Position: LV

Lead Insertion Location: Subclavian vein        PSA Pacing Impedance (ohms): 717

PSA Pulse Width (ms): 0.5                                 PSA Capture Threshold (mA): 0.5

Summary

As is seen in the case above, coders must be vigilant in reading all operative note documentation and implanted device information included in the medical record. Coders must also be aware of all of the characters for the devices inserted in the ICD-10-PCS coding tables. Also, coders must follow official advice such as AHA Coding Clinic First Quarter 2018, page 19. HIAlearn offers the following related courses: Pacemaker Procedure Coding in ICD-10-PCS, Pacemaker Procedure Coding in CPT, Defibrillator Procedure Coding in CPT.

In need of coding support? We offer both inpatient coding support and outpatient coding support services. Partner with us to replace underperforming coding vendors, get coding backlogs caught up, staff for a FMLA/vacation gap, special projects, to assist in Single Path Coding, or for Total Outsource Coding Support.

The information contained in this post 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.