Ask the Expert

This month’s selection:

Our coding team is evaluating how a new procedure done via clinical trial should be reported. However, we haven’t been able to determine the appropriate ICD-9 procedure code assignment.

Physicians at Ohio State’s Richard M. Ross Heart Hospital recently implanted a tiny pacemaker in a Columbus woman as part of a global clinical trial to test its safety and effectiveness. Unlike conventional pacemakers, which require a chest incision and electrical leads that run through a vein to the heart, this device is wireless and threaded through a catheter then attached directly to the heart muscle.

The first implant of this pacemaker was done in April as an outpatient procedure, and an unlisted CPT was charged through the chargemaster for the procedure. We’re now seeing the procedure performed in the inpatient setting.

Medtronic’s website doesn’t offer any coding/reimbursement advice. Unlisted code 37.80 is a possibility, since technically there is no lead(s) placed into a chamber(s), but the difference in reimbursement is significant.

37.80 with Afib as PDx = DRG 259 CMS wt. 1.9462
37.81 or 37.82 or 37.83 with Afib as PDx = DRG 310 CMS wt. 0.5512

I’m looking for some insight regarding this matter and some advice on the proper ICD-9 procedure code assignment.

Chantay Sullivan, RHIA
Inpatient coding manager
Columbus, Ohio

 

Response:

Interesting—it sounds like this device needs its own code since it’s a transcatheter placement, but that won’t happen unless the country gives up on ICD-10 instead of just postponing it eternally. But since it’s a pacemaker, the code assignment will have to be made using the type of pacemaker device and the index and tabular instructions of the codebook.

In essence, 37.80 is the default code for an initial pacemaker placement for a device that doesn’t fit any of the definitions for these other than initial insertion of pacemaker devices.

Dual-chamber device (initial) 37.83
Cardiac pacemaker placed during and immediately following cardiac surgery 39.64
Resynchronization (biventricular)(BiV pacemaker) (CRT-P)
     Device only, initial or replacement 00.53
Single-chamber device (initial) 37.81
     That is rate-responsive 37.82
TEMPORARY transvenous pacemaker system 37.78
     During and immediately following cardiac surgery 39.64

Based on the abbreviated explanation below, if the pacemaker device isn’t a defibrillator, doesn’t have leads, is placed via catheter onto the outside of the heart muscle, and isn’t a temporary placement, then 37.80 should be the correct ICD-9-CM procedure code. Just an FYI, in ICD-9, this isn’t an unlisted code as in CPT but a not elsewhere specified type of code.

I question why this is starting to be performed as an inpatient procedure. Medicare expects a plan for a medically indicated two-midnight stay in order to validate an inpatient status. Medicaid typically expects a procedure to meet medical necessity standards such as Milliman or Interqual in order to pay for the case as an inpatient status. Other third-party payers may need prior authorization for the procedure itself and for inpatient status on a transcatheter procedure, so I’d say the decision to perform the placement as an inpatient procedure is at least as important as the decision regarding what ICD-9 code to use for the procedure.

I see that currently this is a clinical trial, so third-party payment may not be an issue, but medical necessity, the individual patient’s clinical needs, and the relative cost to the facility still should factor into whether the procedure should be performed as an inpatient or outpatient procedure.

— Judy Sturgeon, CCS, CCDS, is the clinical coding/reimbursement compliance manager at Harris County Hospital District in Houston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and compliance for 22 years.