CPT Code 33249: Insertion of ICD with Leads

What is CPT code 33249?

CPT code 33249 documents the insertion or replacement of a permanent implantable cardioverter-defibrillator (ICD) system with transvenous lead(s) in either a single or dual chamber configuration. This code represents a critical cardiac procedure in which an ICD device is surgically placed under the skin and connected to leads threaded through veins into the heart. The implantable cardioverter-defibrillator is a life-saving cardiac electronic device designed to monitor heart rhythms and deliver electrical shocks when it detects life-threatening ventricular tachyarrhythmias or ventricular fibrillation.

The implantable cardioverter-defibrillator serves as a vital intervention for patients at high risk of sudden cardiac death. It continuously monitors the heart's electrical activity and can deliver therapy in various forms:

• Low-energy pacing for minor rhythm disturbances
• Cardioversion for sustained ventricular tachycardia
• Defibrillation shocks for ventricular fibrillation

Patients with severe left ventricular dysfunction, prior myocardial infarction, heart failure, or a history of cardiac arrest may be candidates for this therapy. The device helps prevent sudden cardiac arrest in patients with abnormal heart rhythms that could otherwise prove fatal.

Documentation requirements

Proper documentation for CPT code 33249 must include comprehensive details of the implantation procedure to establish medical necessity and ensure appropriate reimbursement. The Centers for Medicare & Medicaid Services (CMS) frequently attributes insufficient documentation as a cause of denials (Dustman, 2015).

Required clinical documentation

Medical records must demonstrate:

• Clinical symptoms and diagnosis justifying the procedure
• Cardiac disease etiology (ischemic vs. non-ischemic dilated cardiomyopathy)
• Ejection fraction measurements (typically ≤35% for primary prevention cases)
• Documentation of optimal medical therapy trials prior to device implantation
• New York Heart Association (NYHA) heart failure classification
• History of any previous myocardial infarction or coronary artery bypass graft
• Absence of transient or reversible causes for arrhythmias
• Evidence of life-threatening ventricular tachyarrhythmias for secondary prevention cases

Operative documentation

The operative report should include:

• Detailed description of the procedure, including anesthesia used
• Confirmation of a single or dual chamber configuration
• Lead placement verification
• Testing of device functionality (defibrillation threshold testing)
• Complications, if any
• Status of patient post-procedure with stable baseline rhythm
• Defibrillation threshold (DFT) testing is required unless contraindicated (e.g., patient instability)

Suppose a patient has a history of myocardial infarction. In that case, it's important to document that the MI occurred more than 40 days before defibrillator insertion, as this is a criterion for coverage under many insurance plans.

Documentation for medical necessity

To support medical necessity, documentation should also reflect adherence to clinical guidelines for ICD implantation, including:

• Evidence of primary prevention criteria (ejection fraction ≤35%, NYHA class II or III heart failure)
• For secondary prevention, documentation of survived cardiac arrest or sustained ventricular tachycardia
• Evidence that the patient has been on optimal medical therapy
• No contraindications, such as cardiogenic shock or recent acute myocardial infarction

Billing guidelines

Accurate coding and billing for ICD insertions are essential for proper reimbursement and compliance with payer requirements.

Medicare coverage requirements

Medicare covers ICD implantation for patients with ischemic dilated cardiomyopathy with prior MI and LVEF ≤35% and patients with non-ischemic dilated cardiomyopathy lasting more than 9 months with LVEF ≤35%. Additional criteria must be met for both scenarios, as outlined in the Medicare National Coverage Determination.

Modifier usage

Several modifiers may be applicable when billing CPT code 33249, depending on specific circumstances:

• Modifier 26: Professional component
• Modifier 51: Multiple procedures
• Modifier 59: Distinct procedural service
• Modifier Q0: Investigational clinical service (for registry participation)

Medicare administrative contractors

Medicare administrative contractors (MACs) play a crucial role in determining reimbursement for CPT code 33249. These contractors process Medicare claims and can make local coverage determinations that affect how the service is reimbursed. Providers should verify specific coverage details with their respective MACs to ensure compliance with local policies.

Other relevant codes

The following codes can also be considered:

• 33241 - Removal of implantable defibrillator pulse generator only
• 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
• 33249 - Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual chamber
• 33230 - Insertion of implantable defibrillator pulse generator only with existing dual leads
• 33231 - Insertion of implantable defibrillator pulse generator only with existing multiple leads
• 33240 - Insertion of implantable defibrillator pulse generator only with existing single lead
• Z45.02 - An ICD code for encounter for adjustment and management of automatic implantable cardiac defibrillator

Reference

Dustman, R. (2015, August 12). Insufficient documentation no. 1 reason for claims denials. AAPC Codify. https://www.aapc.com/blog/31752-insufficient-documentation-no-1-reason-for-claims-denials/?srsltid=AfmBOoph_kJB1KZjF0PQC6DzSXgRLBSS0b0KDJZJI1YFx9YWtUtoJkO2