Laser Lead Extraction

If you code for a cardiologist, chances are you have coded your fair share of implantable cardiac defibrillator (ICD) and pacemaker lead removals. While these devices are amazing products available due to advances of modern medicine for patients with conditions such as rhythm disorders and heart failure, the leads and batteries in these devices, like any mechanical/electrical device, can breakdown over time. Therefore, it is common to perform procedures for the removal or replacement of these devices.

Before we look at some codes for lead removal and talk about laser lead extraction specifically which is the focus of our article today, let’s look at some terminology you need to know to separate the different code options. This background knowledge will help you when it comes to coding laser lead extractions.

• Pacemaker: An electronic device that regulates the rhythm of the heart. Pacemakers are placed in patients with electrical disturbances in the heart where the rhythm/rate of the heart is abnormal.
• Internal Cardiac Defibrillator (ICD): An electronic device capable of shocking and restarting the heart. These devices are most often placed in patients with heart failure.
• Transvenous: This word means “through or across a vein.” In the context of codes for pacer and ICD lead removal, if the code description states removal of “transvenous” electrodes/leads, the code is used to report removal of leads that were previously placed by accessing a vein such as the internal jugular or subclavian vein and then placing the leads through that vein and into the heart. In this way, you work “through the vein” to gain access to the heart with the leads.  
• Endocardial: “Within the heart.” In the context of pacer/ICD leads, this term refers to transvenous leads that are threaded through the access vein and then into the chamber(s) of the heart.
• Epicardial: “On the surface of the heart.” In the context of pacer/ICD leads, this term refers to leads that are placed by opening the chest through an incision and attaching the leads to the surface of the heart instead of placing the leads transvenously inside the chambers of the heart.
• Single Chamber: A pacemaker or ICD with leads in only one chamber of the heart (i.e., right atrium or right ventricle).
• Dual Chamber: A pacemaker or ICD with leads in two chambers of the heart (i.e., right atrium and right ventricle)
• Multi-Chamber or Biventricular: In the context of pacemakers and ICDs, either term refers to a device with leads in the right atrium, right ventricle, and left ventricle. Sometimes these devices have leads in the right ventricle and left ventricle only without a right atrial lead – that device is still considered “biventricular” since leads are in both ventricles.  

To code removal of leads from a pacemaker or an ICD device, you first need to determine which device the patient has and then look for the approach to removing the leads.

For Transvenous Pacemakers

• 33234: Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular
• 33235: Removal of transvenous pacemaker electrode(s); dual lead system

Coding tips: CPT codes 33234 and 33235 involve opening the pacemaker pocket; disconnecting the leads from the generator; and removing the transvenous leads by twisting, pulling, or putting traction on the leads to remove them.

Code CPT 33235 for removal of transvenous pacemaker electrodes through these methods when the patient has a dual lead (chamber) system (leads in both the right ventricle and the right atrium) whether leads are removed from the right atrium, the right ventricle, or both. The final code is not based on how many chambers from which leads are removed, but on how many chambers in which leads exist at the start of the case.

Also notice, there is no code for removal of “multi-lead” or “biventricular” pacemaker electrodes (where removal of a left ventricular lead(s) occurs in addition to removal of leads from the right atrium and/or right ventricle). Use the dual lead system code when biventricular pacemaker leads are removed through this approach.

• 33238: Removal of permanent pacemaker transvenous electrode(s) by thoracotomy

Coding tip: Code CPT 33238 when pacemaker leads were previously inserted tranvenously, but it is necessary to make an incision in the chest (thoracotomy or sternotomy) to remove the leads. This code is used whether a thoracotomy or a sternotomy approach is used. This open removal usually occurs when leads are surrounded by a lot of scar tissue and cannot be removed transvenously or there is concern for injury to the vena cava. Use this code regardless of the number of chambers in which pacemaker leads exist.

For Epicardial Pacemakers

• 33236: Removal of epicardial pacemaker and electrode(s) by thoracotomy; single lead system, atrial or ventricular
• 33237: Removal of epicardial pacemaker and electrode(s) by thoracotomy; dual lead system

Coding Tips: These codes are used when epicardial pacemaker leads are removed (pacemaker  leads on the surface of the heart). By definition, removing these devices requires the physician to make an incision into the chest (thoracotomy or sternotomy). These codes can be used for either a thoracotomy or sternotomy approach.

Also notice, there is no code for removal of “multi-lead” or “biventricular” pacemaker electrodes (where removal of a left ventricular lead(s) occurs in addition to removal of leads from the right atrium and/or right ventricle). Use the dual lead system code when biventricular pacemaker leads are removed through this approach.

The terms single and dual lead system have the same definitions as they do for transvenous pacemaker leads – use 33237 if removing lead(s) from a pacemaker with electrodes overlying the right atrium and right ventricle whether leads are removed from the surface of the right atrium, the right ventricle, or both.

Finally, these codes unlike 33234, 33235, and 33238 include removal of both the pacemaker generator and the epicardial lead(s). There is no code for removal of epicardial leads alone. In the rare case that epicardial leads are removed and the generator is not, consider adding modifier 52 to the appropriate code.

For Defibrillators:

• 33243: Removal of single or dual chamber implantable defibrillator electrode(s); by thoracotomy
• 33244: Removal of single or dual chamber implantable defibrillator electrode(s); by transvenous extraction

Coding Tips: Unlike our pacemaker lead removal codes, there are not separate codes for removal of single or dual lead systems for implantable defibrillators. Instead there are two codes in total — 33243 for an open chest incision approach which can include removal of leads by thoracotomy or sternotomy and 33244 for transvenous removal which would involve the same methods described for transvenous pacemaker lead removal (pulling, twisting, or placing traction to remove the lead).  These codes are reported regardless of how many leads are removed and regardless of how many chambers in which leads exist.

Laser Lead Removal:

Now that we understand some key terminology and the codes in place in CPT to report removal of the leads of pacemaker and ICD devices, that brings us full circle to our topic of the day, “laser lead removal.”In a limited number of cases, the patient may have significant scar tissue that causes the lead(s) of the pacemaker or ICD system to become stuck to the wall of the vein into which it was inserted. When this occurs, you may see the cardiologist pass a laser sheath into the vein and use that laser to break up the scar tissue and free the lead(s) for removal. We’ve looked at the definitions of many different codes for removing leads of pacemaker and ICD devices, and none of them mention a laser so how is this laser extraction coded?

Per the AMA and professional physician societies, use the normal “transvenous extraction” codes we just discussed (33234/33235 for pacemakers or 33244 for ICDs) and consider adding modifier 22. Modifier 22 is for significant increased complexity and is designed to increase the billed and reimbursed amounts for a given code to reflect that the work involved in a particular procedure was significantly more complex than typical. The modifier in the context of a laser lead removal explains the increased work of removing transvenous lead(s) with a laser sheath. There is an increase in the time it takes to remove the leads as well as in the complexity of the procedure/risk to the patient when this much scar tissue is present. Crediting the modifier is the best way to give the physician credit for this increased work.

It is important to note that there is no separate CPT code for the laser. Coders should not apply an unlisted code with the transvenous code removal or try to use a code such as excision of foreign body from the vein (37197) as these codes do not accurately describe the procedure performed.

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