Cracking the code: Leadless pacemaker implantation

Accurate ICD-10-PCS code assignment requires the coder to have a good understanding of coding guidelines, anatomy, physiology and medical terminology, as well as the ability to decipher the operative report. Assigning PCS codes for pacemaker insertions requires all these skills and more in some cases! Understanding the type of pacemakers and where they are inserted is paramount to correct coding. 

There are two basic types of permanent pacemakers: Traditional devices that require separate generators and lead components, and the newer leadless kind of pacemaker. Traditional pacemaker insertions require separate coding for the insertion of the generator (typically into a pocket on the chest wall) and percutaneous insertion of one or two leads. Leadless or intracardiac pacemakers are reported using a single code for each device inserted. This article will focus on coding leadless pacemaker insertions. 

Leadless pacemaker insertions are coded and reported using the 02H table or the X2H table. The 02H table is used for single chamber devices, while the X2H table is reserved for specific devices that have dual chamber pacing capabilities. Let’s start with the 02H table and explore an example operative report. 
 

Procedure performed: Insertion of Micra™ AV2 

Technique: Through the 8 French safe use stented Amplatz wire was introduced into the superior vena cava. The sheath was then removed and exchanged for a 23 French MICRA delivery sheath system. 2000 UNITS of IV heparin were then given. The sheath was then flushed. Following that the MICRA delivery catheter was introduced through the sheath into the right atrium. The sheath was flexed and the MICRA device was introduced into the right ventricular mid septum. Under fluoroscopy a gooseneck was created to apply gentle pressure on the RV septum. The MICRA Device was then released into the RV septum and the sheath was then pulled back.

To determine the correct code, we must first understand that the Micra AV2 is a leadless pacemaker. If you are not sure, you should always research the specific device that is being inserted. First, check the Device Key found on the Centers for Medicare & Medicaid (CMS) website. If the device isn’t listed, an internet search can help you find the manufacturer’s website. 

In our example, this website contains a brief description stating the Micra AV2 is a leadless pacemaker with automatic atrioventricular (AV) synchrony. Additionally, the operative note specifies that the device was deployed directly to the heart (rather than a subcutaneous pocket in the chest as with a standard pacemaker generator). Since the device is inserted into the heart, the correct PCS table is 02H. 

Below is an excerpt from the 02H table. A leadless pacemaker fits the description of device character N, Intracardiac Pacemaker. Once you select the device character N, you will notice there are a limited number of body part options. The operative note indicates the catheter was introduced into the right atrium; however, this is not where the device was deployed. The entire report needs to be reviewed to know that the physician crossed the RV septum, and the device was delivered to the ventricle. Another key point is that while the Micra AV2 has some functionality like a dual-chamber pacemaker, it is physically located in one chamber of the heart, so it is reported as a single chamber device.

The correct code assignment is 02HK3NZ.
 

02H table

Dual-chamber leadless pacemaker insertions

Next, let’s explore table X2H, the new technology codes that were introduced for fiscal year 2024, effective Oct. 1, 2023, to report dual-chamber leadless pacemaker insertions. These codes are currently only reported for insertion of the Aveir™ Dual-Chamber system. 

This is a modular programmable system comprised of two implanted leadless pacemakers that provide dual chamber pacing therapy: a ventricular leadless device and an atrial leadless device. This device has implant-to-implant (i2i) technology that enables beat-by-beat and bi-directional communication between the two leadless pacemakers and enables them to function as one dual-chamber pacing system. Per the ICD-10 Coordination and Maintenance Committee Meeting, March 7, 2023, ICD-10-PCS Topic #3, Aveir dual-chamber pacing can be achieved in two ways: 

• First, the full dual chamber leadless pacemaker system is implanted with one leadless pacemaker placed in the right atrium and one leadless pacemaker placed in the right ventricle, as a ‘de novo’ system
• Second, a patient who has a single right ventricular leadless pacemaker in-situ is upgraded to dual chamber leadless pacemaker system by having one leadless pacemaker inserted into the right atrium only

Operative notes for both types of leadless pacemakers will be similar, however, understanding where the device is placed, as well as knowing the brand and type of implant is critical to correct coding. Below is an excerpt from the X2H table. When device character V is selected, there are only two body part options available. If both atrial and ventricular devices are implanted at the same time, X2H63V9 and X2HK3V9 should be reported. To report X2H63V9 for the second, upgrade option, the coder must verify that the existing ventricular intracardiac device is the Aveir System Dual-Chamber component. It is the i2i technology that makes the two separate devices function as a dual-chamber device. The only way this works is if both devices are components of the Aveir System. If the existing device is not part an Aveir system, the implantation of the atrial device is reported using the 02H table as previously discussed. 
 

X2H table

Dual-chamber leadless device insertion should be documented as Aveir DR Leadless pacemaker implantation, Aveir DR LP implantation, Aveir DR permanent leadless pacemaker implantation or similar language to use the X2H table.  The coder must review the entire procedure note, including the list of implants, to ensure the correct code assignment. 

For more information, please review the Coordination & Maintenance Committee Meeting minutes from March 7, 2023, Topic 3-Insertion of a Dual-Chamber Leadless Cardiac Pacemaker. ICD-10-CM/PCS Coding Clinic, Fourth Quarter, 2023, page 60-61 also provides coding advice for dual-chamber intracardiac pacemaker insertions. 

In summary, the coder must first determine if the device being inserted is leadless or requires leads to function. This information will determine the correct device character. Once the coder has determined that a leadless device was inserted, they must then determine if this device has single or dual-chamber capabilities. This does not simply mean that a device was deployed to both the atrium and the ventricle. To be reported as a dual chamber intracardiac pacemaker, the devices must contain technology to allow them to communicate with each other. As of this publication, the only device that meets this criterion are the Aveir DR Leadless pacemaker system or the Aveir AR System when inserted as an upgrade. 

Teresa Seville, RHIT, CCS, is a development analyst with Solventum.