Cardiac Lead Removal:
Reimbursement Levels and Financial Viability 

Charles W. Coates, Senior Product Manager
Spectranetics Corporation, Colorado Springs, CO

Introduction 
Spectranetics has long received reports from physicians about insufficient reimbursement levels for performing cardiac lead removal procedures. As the cardiac lead removal specialty grows, more and more of these physicians have asked Spectranetics to help them investigate the reimbursement system to determine if there are ways to make reimbursement more reflective of the time and effort expended on these procedures. In other words, is removing cardiac leads financially viable in light of low federal, state and private insurance reimbursement levels? 

Spectranetics looked at various sources that provide information on Medicare reimbursement. After a thorough review of available data it was determined that an outside agency was the most expeditious way to look at reimbursement on a national level. Spectranetics hired JR Associates, A Healthcare Resource Company, respected for its expertise in the area of reimbursement to research the subject. 

Research Methodology 
JR Associates first looked at the relationship between payers and providers. Second, it examined current cardiology criteria (codes) required for the successful reimbursement of specific lead removal procedures. Third, it looked at past and present Medicare average reimbursement amounts for lead removal procedures. 

Spectranetics customers (physicians, department managers, chief technologists) were interviewed to determine their coding and payment practices. While cooperative, JR Associates found their level of knowledge about payment and coding varied. Operative reports and associated billing forms were collected and submitted to various experts by JR Associates to examine and re-code as appropriate. Responses were compared to determine differences in coding approaches and the affect on payment levels. 

Research Findings: An Issue of Coding
It was found that Medicare and private payers do cover pacemaker and AICD cardiac lead removal procedures. Spectranetics also found that payers recognize pacemaker and AICD cardiac lead extraction as a covered service. 

Correct coding was identified as one of the most complicated obstacles to receiving payment. Codes end up acting as the reporting mechanism that links payment to procedures performed. 

The Health Care Financing Administration Common Procedure Coding System (HCPCS) contains three levels of codes: Levels 1, 11 and 111. For purposes of this monograph we concentrate on Level 1, referred to as Current Procedural Terminology codes, or CPT codes. 

The CPT coding system is a national coding system designed to describe services and procedures at any service site. The AMA administers and publishes the CPT manual. The manual is updated annually. CPT codes contain five digits. Currently, CPT codes that describe lead removal refer to both conventional and laser methods of lead extraction. 

Pacemaker and AICD implantation and replacement codes are in the 33200 series (see Table 1). Pacemaker lead extraction codes are grouped from 33234 to 33235, and AICD codes are 33241 to 33249. Codes reported here include revisions for year 2000 in the areas of pacemakers and AICD.

TABLE I.

CPT codes divide pacing and AICD procedures into three broad categories: insertion, replacement and removal of pulse generators and leads. Multiple combinations of CPT codes are used to describe lead and/or pulse generator removal. As noted in Table 2, if a pulse generator and a lead are replaced, separate codes for the removal and insertion are reported. 

TABLE 2.

Although CPT coding appears simple, it is very complex -- so complex it has spawned an industry of its own. While the listing of CPT codes appears straightforward, there are many coding and payment rules as well as other components that make up the procedures to be considered. For example, the physician is also allowed to report the radiologic supervision and interpretation of the fluorscopy. Also, when a CPT code does not quite fit the description of the service performed, a modifier is used. For example, if a lead removal procedure took an exceptional amount of time then a modifier such as -22 is added. A transvenous pacemaker electrode with unusual complications is reported as 33234-22. An operative report and a letter from the physician should accompany the claim describing the complication, i.e., why it took longer. In a case like this, Medicare would pay about 30% more if allowed.

It is important to note that correct coding is a "must" for proper reimbursement, as these codes are the only way to capture all of the components of a procedure. Based on a review of operative reports, coding experts coded the same procedure in various ways, resulting in payments from as low as $500 up to $1,500. This is not an exact science, but it serves physicians well to examine their coding practices carefully. 

Scenarios contained in Table 2 illustrate a single, dual chamber pacemaker procedure and an AICD procedure. 

In addition to CPT codes, International Classification of Diseases, or ICD-9 diagnosis codes are paired with CPT codes to demonstrate the medical necessity of services rendered. These codes use three to five digits to represent the principle diagnosis and to trigger reimbursement. They are complex diagnosis codes and should be reported to the highest specificity. An example of ICD-9 code usage is the 412 code for an old MI. If the MI is acute, a fourth and fifth digit are added to describe the location and other conditions such as 410. 10 (acute anterior wall MI). 

Research Findings: A Matter of Financial Averages 

Once provided services are properly coded, they are submitted to a contracted Medicare reviewing agency. These carriers administer Medicare Part B, which covers the physician fee for the service. 

In 1992, a national fee schedule was put into effect for payments under Medicare Part B. This fee schedule is based on national uniform relative values (REV) that represent the cost of service rather than the amount charged. The RVU is allocated as follows: Physician Work (54%) of total value of service; Practice Expense (41%) of total value of service; Malpractice Insurance (3%) of total value of service. From this rather complex accounting, physicians are paid 80% of the allowable amount listed in the fee schedule. The remaining 20% is paid by the service recipient or secondary insurance. The difference between the allowable amount and the amount charged is a contracted write-off for the physician and cannot be collected. Table 3 provides an example of 1999 and 2000 RVUs assigned to pacemaker and AICD procedures. Additionally, the AMA revised many of the pacemaker and AICD CPT codes to reflect a more accurate description of procedures and new technology. This resulted in a redistribution of the RVUs within the pacemaker and AICD series, positively affecting reimbursement for lead removal. 

TABLE 3.

RVUs are multiplied by a conversion factor of $36.6137, increased by 5% in 2000, to establish the payment amount. Based upon this conversion factor and increased value, physician payments were augmented for the year 2000. 

Table 4 illustrates that increases in allowed payments for year 2000 are more than a case of statistics. 

TABLE 4.

As a service to its lead removal customers, Spectranetics had JR Associates review the process of physician reimbursement. It found that allowed payments for cardiac lead removal were increased for year 2000, and projects a continued increase through 2002. These changes indicate an increased awareness among physicians and government officials of the importance of the cardiac lead removal procedure for both patients and providers. It also appears that cardiac lead removal is increasingly considered a specialty in its own right.