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A subcutaneous rhythm monitor (sometimes referred to as an implantable cardiac monitor or an implantable loop recorder) is a device inserted into a pocket underneath the skin that provides long-term monitoring of the patient’s heart rate. Unlike a holter monitor which involves placement of electrodes and the use of an external recording device worn by the patient over a period of 2-15 days, these devices are useful for monitoring heart rhythm over a longer period of time when there is a need to better understand the trends and determine if a pacemaker is needed.

While most patients have the subcutaneous rhythm monitor inserted, are monitored, and then have the device removed (with or without placement of a pacemaker), some patients may require monitoring over a period of several years which could require replacement of the device. You will notice that we have clear codes for insertion of a subcutaneous rhythm monitor (33285) and removal of one (33286). But how is a replacement of this device coded?

It depends. There is no dedicated code for replacement of a subcutaneous rhythm monitor. There is also an NCCI edit between codes 33285 (insertion of the new device) and 33286 (removal of the old). The rationale for the edit is that the two codes represent “mutually exclusive procedures.” This means that the two codes cannot reasonably be reported together at the same anatomic site or at the same encounter.

So the final coding comes down to the timing of the two procedures and whether the new device is placed in the same location as the original device:

• If the original subcutaneous rhythm monitor is removed and a new device placed through the same incision, code for the insertion of the new device only (33285). I would apply this same guideline even if there is some “tunneling” under the surface of the skin to create a new pocket for the replacement device– one incision equals code 33285 only.

• If, however, the old subcutaneous rhythm monitor is removed and a new device is placed through a separate incision you can report 33285 and 33286 with modifier 59 (or modifier XS) to show that the new device is inserted through one incision and the old device removed through a separate incision at a separate anatomic site. As an example, you may see this in patients who have an infection in the location where the original monitor was inserted with a need to move the new device to a completely different location away from the infection.

• You could also report 33285 and 33286 with modifier 59 (or modifier XE) if for some reason the old monitor was removed during one encounter and the new monitor was inserted at a separate encounter later on the same day. This would be very rare, but I did want to cover the coding of this scenario in case you see it in your coding.

References:

• 2021 NCCI Practitioner Procedure-to-Procedure (PTP) Edits Effective January 1, 2021: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits
• 2021 NCCI Policy Manual, Chapter 1, General Correct Coding Policies (Section P – Mutually Exclusive Procedures): https://www.cms.gov/files/document/chapter1generalcorrectcodingpoliciesfinal112021.pdf

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Today’s article will be dedicated to discussing the anatomy of the sinuses and to providing an overview of some of the key codes and guidelines in the sinus endoscopy section of CPT. There were some pretty sweeping changes to the sinus endoscopy codes in 2018, and those changes are still generating questions and confusion for physicians and coders alike on how these new codes were intended to be used.

Before we look at specific CPT codes and examples, let’s begin by reviewing the anatomy of the sinuses. Patients with normal anatomy have four sinuses in total. Each of these sinuses is “paired” with one sinus cavity on the left and the other on the right: