ICD / Pacemaker Implantation

CPT 33249
Approach Minimally Invasive
Add-on / Variant CPTs
  • 33206 — Insertion of permanent pacemaker with transvenous electrode(s); atrial
  • 33270 — Insertion/replacement of subcutaneous ICD (S-ICD) system
  • 33208 — Insertion of permanent pacemaker with transvenous electrode(s); atrial and ventricular
Preoperative Diagnosis:

[Ventricular tachycardia / ventricular fibrillation / reduced EF <35% with NYHA Class II-III / complete heart block / sick sinus syndrome], requiring [ICD / permanent pacemaker] implantation

Postoperative Diagnosis:

Same

Procedure Performed:

[Dual-chamber ICD / single-chamber ICD / dual-chamber permanent pacemaker / CRT-D / CRT-P] implantation, [de novo / upgrade / generator change]

Attending Surgeon:

[Attending name], MD/DO [EP/Cardiac Surgery]

First Assistant:

[Nurse/tech name]

Anesthesia:

Monitored anesthesia care [/ general] with local: [X] mL 1% lidocaine

Indications:

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.

Findings:

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.

Description of Procedure:

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.

Complications:

None

Specimens:

None

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

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
.TODAY
Variants

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. Subclavian access carries pneumothorax risk; cephalic cutdown is safer but not always possible. Document the access method used and that post-procedure CXR confirmed no pneumothorax.
  • Document ICD defibrillation threshold (DFT) testing if performed. DFT testing is not universally performed, but when done, document the induced VF, successful termination, and the shock energy. If DFT was deferred, document the reason.
Billing Tips
  • Bill 33206 for single-chamber pacemaker implant with atrial lead (6.96 wRVU, 90-day global). Bill 33207 for single-chamber with ventricular lead (7.61 wRVU). Bill 33208 for dual-chamber pacemaker (8.31 wRVU).
  • Bill 33249 for ICD implant with defibrillation leads (14.55 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.
  • When lead revision only is required (without generator change), use 33215-33218 for pacemaker lead revision or 33218-33220 for ICD lead revision. Generator change alone (without lead work) uses 33227-33229 (pacemaker) or 33262-33264 (ICD).