ICD / Pacemaker Implantation
3324933206wRVU: 6.96 — Single-chamber PPM, atrial lead (alternative primary code; 7.63 wRVU)33207wRVU: 7.61 — Single-chamber PPM, ventricular lead (alternative primary code; 7.81 wRVU)33208wRVU: 8.31 — Dual-chamber PPM, atrial and ventricular leads (alternative primary code; 8.60 wRVU)33270wRVU: 8.87 — Subcutaneous ICD (S-ICD) insertion or replacement (alternative primary code for subcutaneous device)33274wRVU: 7.61 — Leadless pacemaker (MICRA), transcatheter insertion (alternative primary code for leadless device)
[Ventricular tachycardia / ventricular fibrillation / reduced EF <35% with NYHA Class II-III / complete heart block / sick sinus syndrome], requiring [ICD / permanent pacemaker] implantation
Same
[Dual-chamber ICD / single-chamber ICD / dual-chamber permanent pacemaker / CRT-D / CRT-P] implantation, [de novo / upgrade / generator change]
[Attending name], MD/DO [EP/Cardiac Surgery]
[Nurse/tech name]
Monitored anesthesia care [/ general] with local: [X] mL 1% lidocaine
The patient is a [age]-year-old [male/female] with [LVEF X% / recurrent VT/VF / complete heart block / sinus node dysfunction], meeting criteria for [ICD / PPM] implantation per [AHA/ACC/HRS guidelines]. The risks, benefits, and alternatives were discussed and informed consent was obtained.
Venous access was obtained via the [left / right] subclavian [/ axillary / cephalic] vein. Lead impedances, sensing, and pacing thresholds were acceptable. [ICD: defibrillation threshold was [<25 J] confirmed. R-wave sensing was [X] mV.] Device position was confirmed by fluoroscopy.
The patient was positioned supine on the fluoroscopy table. The [left / right] chest was prepped and draped. Local anesthesia was infiltrated subcutaneously and along the dissection plane. A [5]-cm incision was made [2 cm below the clavicle] over the pectoralis fascia.
The subclavian [/ cephalic / axillary] vein was accessed with a [modified Seldinger technique / direct cutdown (cephalic vein)]. A [7 Fr / 9 Fr] peel-away introducer was placed. [For dual-chamber: a second venous puncture was made for the second lead.]
[VENTRICULAR LEAD:] A [screw-in / passive-fixation] [RV apical / septal] lead was advanced under fluoroscopic guidance through the right atrium, across the tricuspid valve, to the [right ventricular apex / mid-septum]. The lead was secured. Pacing threshold: [X] V at [0.4 ms] pulse width. R-wave amplitude: [X] mV. Impedance: [X] ohms.
[ATRIAL LEAD:] A [screw-in] right atrial appendage lead was positioned. P-wave sensing: [X] mV. Pacing threshold: [X] V. Impedance: [X] ohms.
[CRT / LV LEAD: The CS was cannulated and a LV lead was advanced to the [lateral / posterolateral] CS branch. LV threshold: [X] V. Impedance: [X] ohms.]
[ICD: DFT testing was [performed / deferred]. Induced VF terminated at [X] J.] The leads were anchored to the pectoralis fascia with [0-Silk] suture. A pocket was created for the generator. The [model/manufacturer] [ICD / pacemaker] generator was connected, and the pocket was closed in [2-3] layers. A sterile dressing was applied.
Final fluoroscopic images confirmed lead positions.
None
None
Minimal
None
The patient was monitored post-procedure. Chest X-ray confirmed [appropriate lead positions / no pneumothorax / no hemothorax]. The device was interrogated and programmed per EP protocol. [Activity restriction: no overhead use of the ipsilateral arm for [4-6 weeks].]
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***, requiring *** implantation
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** (ICD/PPM) implantation, ***
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: MAC + local
INDICATIONS: .PTAGE-year-old .PTSEX with ***. LVEF ***%. Meets criteria for ***. Consent obtained.
FINDINGS: *** venous access. Lead parameters: RV threshold *** V, R-wave *** mV, impedance *** ohms. RA threshold *** V, P-wave *** mV. [DFT: VF terminated at *** J.]
PROCEDURE:
Supine, fluoro table. *** chest prepped. Local anesthesia. *** cm incision below clavicle. *** venous access, peel-away introducer. [RV lead: *** fixation to *** position, fluoroscopy confirmed.] [RA lead: RAA, fluoroscopy confirmed.] [LV lead: CS cannulated, *** branch.] Leads anchored to fascia. Generator pocket created. *** generator connected. Closed *** layers. CXR: leads appropriate, no PTX.
EBL: Minimal
COMPLICATIONS: None
DISPOSITION: Monitored. Device programmed. Arm restriction × 4-6 weeks.
Signed: .ME, .MYDEGREE
.TODAYVariants
Generator Change (Battery Depletion)
Generator change was performed for battery depletion [elective replacement indicator (ERI) reached]. The existing pocket was opened. The generator was disconnected from the leads. Lead impedances and sensing/pacing thresholds were measured and documented before and after generator exchange. A new [model/manufacturer] generator was connected. The pocket was irrigated and closed in layers. Lead parameters at the new generator: [thresholds as documented above]. No lead revisions were required.
Charting Tips
- Document all lead parameters (threshold, sensing, impedance) at implant. These values are the baseline for future device follow-up. A pacing threshold >1.0 V at 0.4 ms or R-wave <5 mV should prompt lead repositioning before pocket closure. Document the final accepted values.
- Document venous access method and any complications. Cephalic vein cutdown avoids pneumothorax and subclavian crush but is not always possible. Axillary vein access (extrathoracic, lateral to first rib) is increasingly the preferred approach at high-volume centers, avoiding both pneumothorax and lead crush. Subclavian access carries pneumothorax risk and lead crush risk over the first rib. Document the access method used and that post-procedure CXR confirmed appropriate lead positions and no pneumothorax.
- Document DFT testing status. Following the SIMPLE trial (2015, Lancet), routine DFT testing at implant has been largely abandoned — deferral is now standard for most left-sided transvenous ICD implants. Document that DFT testing was deferred and note any patient-specific reasons (high-risk anatomy, prior failed shock, etc.). When DFT is performed, document induced VF, successful termination, and energy delivered.
Billing Tips
- Bill 33206 for single-chamber pacemaker implant with atrial lead (7.63 wRVU, 90-day global). Bill 33207 for single-chamber with ventricular lead (7.81 wRVU). Bill 33208 for dual-chamber pacemaker (8.60 wRVU). These are alternative primary codes; select based on the number and position of leads implanted.
- Bill 33249 for transvenous ICD implant with defibrillation leads (16.63 wRVU, 90-day global). ICD codes have a substantially higher wRVU than pacemakers. Confirm whether the device is a pacemaker or ICD before coding.
- Device programming, threshold testing, and pre-discharge interrogation are bundled into the implant code. Do not separately bill device check (93280-93284) at the time of implant. Post-discharge device checks are separately billable.
- 90-day global period: wound check, device interrogation at the 2-week visit, and antibiotic management are bundled. Device revision or lead repositioning within the global period requires modifier -78.
- For lead revision without generator change: 33215 (repositioning of previously implanted electrode), 33216 (insertion of new electrode, single), 33217 (insertion of new electrode, dual), 33218/33220 (repair of electrode). Generator change without lead work: 33227-33229 (pacemaker) or 33262-33264 (ICD). Use modifier -78 when returning to OR within the 90-day global for device-related revision.
General coding reference. Verify with your institution’s billing department before submitting claims.