Author: Kimberly Mansingh

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.

If you have been coding surgeries for awhile, you’ve likely seen the term “separate procedure” in some of the descriptions for the codes you use. Codes with the term “separate procedure” in their code descriptions are said to have a “separate procedure” designation in CPT (this is a phrase you may see in guidelines from the AMA and CMS). Even though this term has been used in CPT for many years, it is still a source of a lot of questions for coders and many inquiries I see on coding forums. Some people look at the term “separate” and think that a separate procedure is something that should always be reported separately (or in addition to) other codes on the claim. What the term “separate” in this phrase really means, though, is quite the opposite.

A “separate procedure” according to CPT guidelines is a procedure that is usually a routine part of completing a more comprehensive procedure. CPT states that you should not code a CPT with the terminology “separate procedure” in its code description when you are reporting a more extensive procedure that separate procedure is a part of. However, you can report a code with a “separate procedure” designation in its code description if it is 1) the only procedure performed and billed during that surgery or 2) is performed with other procedures that it is not a routine part of.

The NCCI Policy Manual, which is published by the Centers for Medicare and Medicaid Services (CMS), also contains guidelines regarding codes with a “separate procedure” designation in their description. In Chapter 1 of this manual in section J, the guidelines say that “If a CPT code descriptor includes the term separate procedure, the CPT code may not be reported separately with a related procedure. CMS interprets this designation to prohibit the separate reporting of a separate procedure when performed with another procedure in an anatomically related region often through the same skin incision, orifice, or surgical approach.” The guidelines make it clear that you should not report a code with the terminology “separate procedure” in the code description when it is performed with a “related procedure.” They further define related procedures as those occurring through the same incision, orifice (e.g., nasal, oral, etc.), or surgical approach (e.g., through the same endoscope).

The guidelines in this same chapter and section also clarify when it would be appropriate to report a CPT code with a “separate procedure” designation along with another CPT code: “A CPT code with a separate procedure designation may be reported with another procedure if it is performed at a separate patient encounter on the same date of service or at the same patient encounter in an anatomically unrelated area, often through a separate skin incision, orifice, or surgical approach. Modifier 59 or a more specific modifier (e.g., anatomic modifier) may be appended to the separate procedure CPT code to indicate that it qualifies as a separately reportable service.” Before reporting a code with a “separate procedure” designation with another CPT code during the same surgery, look to see if the two procedures happen in anatomically unrelated areas and are completed through separate incisions or approaches.

To give an example, CPT 44005 is coded for lysis of adhesions. This is a surgical procedure where the surgeon creates an incision in the abdomen and breaks apart adhesions that have formed in the abdomen due to an infection or a prior surgery. CPT 44005 has a “separate procedure” designation in its description: Enterolysis, freeing of intestinal adhesions (separate procedure). Since CPT 44005 has the “separate procedure” designation, it would be appropriate to report this code in a couple of circumstances:

1) If lysis of adhesions was the only surgical procedure performed on that patient during that surgery, you can report CPT 44005 by itself. In this scenario, the lysis of adhesions was the planned procedure and the only procedure performed.

2) If lysis of adhesions is performed at one time during the day (e.g., 9:00 a.m.) and later that same day another abdominal procedure (e.g., a colectomy) is performed, you can report the lysis of adhesions in addition to the other abdominal procedure since the two occurred at different encounters.  Modifier 59 or XE (separate encounter) would be added to CPT 44005 to clarify that the two procedures happened during separate encounters.

3) If lysis of adhesions was performed along with another procedure somewhere else in the body during the same surgery (e.g., lysis of adhesions in the abdomen and removal of a cyst from the arm), you could report both codes. In this scenario, the lysis of adhesions is not a routine part of removing the cyst in the arm but is totally unrelated to that second procedure and performed in an “anatomically unrelated area” through a “separate incision.” Therefore, you can justify reporting CPT 44005 with another code even though it has a “separate procedure” designation.

The scenarios above clarify when you can report lysis of adhesions (a CPT code with a “separate procedure” designation). However, there are also many surgeries where you cannot report lysis of adhesions separately. Lysis of adhesions performed during any other abdominal procedure (e.g., a gastrectomy, colectomy, appendectomy, cholecystectomy, etc.) cannot be billed separately. The reason the lysis of adhesions bundles during any other abdominal procedure is because, to gain access to the abdominal organs such as the stomach, colon, appendix, gallbladder, etc., it is necessary to first break up the adhesions. Therefore, the lysis of adhesions in this scenario is a routine part of completing the more comprehensive procedure and would be bundled.

What “separate procedure” scenarios have you encountered? A key part of coding is networking with other coders and learning together. Please share your experiences and questions in the comments field below.

If you work for a surgeon specializing in colorectal procedures, chances are you have seen your fair share of ostomy takedown procedures. When you first start checking CPT for a code for a “takedown,” though, you may find yourself coming up empty. The reason for this is that surgeons use the term takedown in their operative reports while CPT uses the word “closure” in the codes that cover this procedure. Both terms really have the same meaning, but until you know about the difference in language you may see in reports verses what you will see in the CPT manual, the whole thing can be pretty confusing. So let’s breakdown the terminology and codes for an “ostomy takedown” and see how that looks in CPT so you can quickly choose the correct code.

CPT describes an “ostomy takedown procedure” as “closure of an enterostomy.” An enterostomy is a surgically-created connection between part of the intestine and another structure. We can confirm the definition of enterostomy by breaking the word down into its parts: entero- means “of or pertaining to the intestine” (this could refer to either the small or the large intestine) while -ostomy means “an artificial opening between two structures.” So when we put these word parts together we have “an artificial opening between a part of the intestine and another structure.” In the context of these codes, the artificial connection was made between one end of the intestine and the abdominal wall. Some common enterostomies you may see include an ileostomy (connection between part of the last segment of the small intestine and the abdominal wall) and a colostomy (connection between any part of the large intestine, aka as the colon, and the abdominal wall). The CPT codes for the takedown procedure start with the word “closure.” The reason we see the word “closure” is because the surgeon will ultimately close up that artificial opening (or ostomy site) on the abdominal wall in a takedown procedure. So surgeons refer to these procedures as a “takedown” clinically because they are taking the end of the colon or small intestine that was connected to the abdominal wall back down into the abdomen while CPT calls these “closure of an enterostomy” because the surgeon is ultimately closing up that artificial opening on the abdominal wall. Both terms again really refer to the same procedure, but hopefully this explanation will help you line up the language you see in operative reports and what you see in your CPT manual.

With those definitions in mind, here are the three code choices for closure of an enterostomy:

• CPT 44620: Closure of enterostomy, large or small intestine

• CPT 44625: Closure of enterostomy, large or small intestine; with resection and anastomosis (other than colorectal)

• CPT 44626: Closure of enterostomy, large or small intestine; with resection and colorectal anastomosis (e.g., closure of Hartmann type procedure)

Let’s start breaking down the difference in these codes. Starting with CPT 44620, this is your code for your “basic” takedown procedure. In this procedure, the surgeon disconnects the end of the small or large intestine from the abdominal wall and reconnects that end to the remaining intestine back inside the body. He then closes the former ostomy opening on the abdominal wall. No part of the intestine is removed in this procedure. Instead, the end that was attached to the abdominal wall is simply reconnected (aka anastomosed) to the remaining intestine without resecting part of the intestine.

For CPT 44625, the physician is still disconnecting the end of the small or large intestine from the abdominal wall, but before reconnecting the end of the intestine to the remaining intestine in the body, part of the intestine that was connected to the abdominal wall and/or part of the remaining intestine “stump” (the end of the intestine that was inside the body) will be resected and removed. After removing the appropriate amount of intestine, the two ends of the intestine will be anastomosed back together. For CPT 44625, the anastomosis performed is any anastomosis other than colorectal. So in this procedure, you may see various parts of the intestine reconnected such as ileum to ileum, ileum to remaining colon, colon to colon, etc. If two structures other than the colon and the rectum are reconnected after removing part of the intestine and closing the ostomy site on the abdominal wall, it’s a 44625.

Finally, for CPT 44626, this procedure includes very similar work to what is described by CPT 44625, but in this procedure, the two structures anastomosed are the colon and the rectum (aka a colorectal anastomosis). This procedure may also involve resection of part of the remaining colon and part of the remaining rectum before creating that colorectal anastomosis. You will notice in the parentheses in the code description that CPT states this procedure may be coded for closure of a “Hartmann’s type procedure.” In a typical Hartmann’s procedure, one end of the colon is brought out to the abdominal wall as a colostomy while the remaining rectal “stump” is stapled closed. So in reversing a Hartmann’s, the surgeon would typically resect part of the colon that was attached to the abdominal wall and maybe “clean up” the end of the rectal stump and then perform a colorectal anastomosis. That’s why closing the ostomy created during a Hartmann’s procedure would typically fall under CPT 44626. It is important to note, though, that most but not all Hartmann procedure takedowns would be coded as 44626. In a modified Hartmann’s procedure, the surgeon will connect one end of the colon to the abdominal wall as a colostomy and then staple closed a “long Hartmann’s stump” that includes part of the sigmoid colon plus the rectum. If the surgeon closes the ostomy at a later date and the anastomosis created is between part of the colon that was connected to the abdominal wall as an ostomy and the sigmoid colon (rather than the rectum), you would code CPT 44625 (since the anastomosis would be colon to colon instead of colorectal). Small details here would make a difference in the coding.

Now that we have reviewed the codes, let’s look at a couple of examples to illustrate appropriate coding of these procedures.

Example #1: After sterile prep and drape, we made an incision through our previous midline laparotomy. Dense adhesions were encountered, but we were eventually able to gain access to the transverse colonic stump. We removed roughly 5 cm of colon to ensure no ischemic bowel remained. We then turned our attention to the abdominal wall where we circumferentially dissected around the ileostomy site. The end of the ileum appeared dusky so we removed 10 cm of ileum and then brought the remaining intestine down into the abdomen. The remaining ileum and transverse colon were aligned and using an EEA stapler, the anastomosis was complete. The ends of the bowel came together nicely in a tension-free anastomosis. We checked to ensure we had an airtight anastomosis and applied some Arista powder to ensure hemostasis. We then closed our opening on the abdominal wall and closed our midline incision. The patient tolerated the procedure well.

Answer Example #1: The bolded portions of the note above are keys to selecting the correct CPT code. We first see the physician enter the abdomen (a laparotomy is an incision into the abdomen), and he finds the “transverse colonic stump” (or the part of the intestine that was stapled off in the body during the prior surgery where the ostomy was created). He “removes” 5 cm of transverse colon (which is our first intestinal resection). He then comes up to the abdominal wall and circumferentially dissects (or separates all the way around) the connect between the ileostomy (the end of the ileum) and the abdominal wall. He then performs a second intestine resection, removing 10 cm of the ileum. Then he brings the ileum back into the abdomen, lines up the ileum and the transverse colon, and using a stapler creates an anastomosis (a connection between the remaining ileum and the colon). After making sure his anastomosis is intact by testing for leaks and controlling any bleeding (which is all part of the main procedure), he closes the opening from the ostomy on the abdominal wall. So we have closure of an enterostomy (in this case an ileostomy), with resection of intestine, and an anastomosis other than colorectal (since the anastomosis is between the ileum and the transverse colon). Those details support CPT 44625.

Example #2: After sterile prep and drape, we made an incision through our previous midline laparotomy. Dense adhesions were encountered, and we spent 90 minutes lysing adhesions to gain access to the abdomen. Access was very difficult due to multiple prior abdominal surgeries. Eventually we located our rectal stump. We opened up the prior sutures at the rectal stump and then turned our attention to the abdominal wall. We then circumferentially freed the colostomy from the abdominal wall. We resected 15 cm of colon then brought the remaining intestine down into the abdomen, ensuring we had adequate length to reach the rectum. The remaining colon and rectum were aligned. We passed the anvil of our EEA stapler into the remaining colonic end and passed the stapler via the anus. With a single fire, the anastomosis was complete. We introduced water into the pelvis and air into the colon via a rigid proctoscope to ensure there were no bubbles and verify that our anastomosis was intact. With this complete, we then closed the prior colostomy site on the abdominal wall and closed our midline incision. The patient tolerated the procedure well.

Answer Example #2: The bolded portions of the note above are keys to our code selection. We first see the surgeon entering the abdomen. In this case, the entry into the abdomen is significantly more complex than normal (he tells us he spent 90 minutes lysing/breaking up adhesions to gain access to the rectal stump due to the multiple prior abdominal procedures). We want to keep this detail in mind once we find our CPT code because this is a good example of a case where modifier 22, significant, increased complexity, could apply. He then tells us he “located the rectal stump” and “opens the prior sutures” (so he is preparing the rectal stump for anastomosis). He doesn’t remove any of the remaining rectum, and that’s okay (he is not required to do so, but may choose to remove part of the rectum when circumstances warrant that). He then comes up to the abdominal wall and frees the colostomy from the abdominal wall all the way around. He then removes (aka resects) 15 cm of the colon (so that’s our intestinal resection). He makes sure he still has good length of colon to reach the rectum and brings the colon down into the abdomen where he lines it up with the rectal stump. The bolded portions here are key words that describe using tools such as staplers and anvils to bring the colon and the rectum back together (aka a colorectal anastomosis). He then checks for leaks (again no matter how they do that through water, air, a scope, etc. that is all part of the main procedure). The surgeon then closes the ostomy opening on the abdominal wall. So we have a takedown of a colostomy, resection of part of the colon, a colorectal anastomosis, and closure of the opening on the abdominal wall. These details support CPT 44626. Again, I would also add modifier 22 and diagnosis code K66.0 (postoperative adhesions of the intestine) due to the 90 extra minutes it took to gain access to the abdomen at the start of the case.

I hope the explanations and examples in this article help you code ostomy takedowns with confidence. If you have an example that wasn’t addressed in this article, please reach out in the comments section below.

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The topic of scout endoscopies is one that comes up often for coders in all different specialties because surgeons often perform these procedures during non-endoscopic procedures in the chest, abdomen, and pelvis to help them visualize the organs/structures they are working on or ensure successful completion of their procedure. Distinguishing a diagnostic endoscopy from a scout endoscopy can be difficult at first, but fortunately, we have some guidelines that can help us.

In the NCCI Policy Manual which is published each year by the Centers for Medicare & Medicaid Services (CMS) a “scout endoscopy” is defined a couple of different ways. The first definition we see for a “scout endoscopy” is a type of endoscopy that may be performed before a non-endoscopic surgery:

A “scout” endoscopy to assess anatomic landmarks or assess extent of disease preceding another surgical procedure at the same patient encounter is not separately reportable. – NCCI Policy Manual, Chapter 6, section C.6