Cardiac implantable electronic devices (CIEDs)—including pacemakers and implantable cardioverter-defibrillators (ICDs)—are among the most regulated procedures in cardiovascular medicine. Because implantation, revision, replacement, interrogation, and programming all have separate CPT codes with strict bundling and supervision requirements, billing errors can easily lead to denials or audit risk.
This guide provides a comprehensive overview of CPT codes, documentation expectations, global period rules, technical/professional splits, payer nuances, and compliance considerations for both pacemaker and ICD services.
Understanding Pacemaker & ICD Structures
Both pacemakers and ICDs typically involve:
- Pulse generator (battery + electronics)
- Leads (atrial, ventricular, coronary sinus)
- Programmer-based management (interrogation, analysis, reprogramming)
Billing rules differ based on:
- Whether a single-, dual-, or biventricular system is involved
- Whether the service is an initial implant, upgrade, revision, lead replacement, lead reposition, generator change, or device removal
- Whether the service is remote monitoring, interrogation, or in-person programming
- Who provided the technical versus professional components
Pacemaker Implantation CPT Codes
Pacemaker implants are coded based on the number of chambers paced.
Single-Chamber Pacemaker Insertion
- 33206 – Atrial or ventricular lead + generator insertion
- 33207 – Ventricular only
- 33208 – Dual-chamber pacemaker (atrial + ventricular leads)
Key Documentation Must Include:
- Indication (e.g., sick sinus syndrome, complete AV block, symptomatic bradycardia)
- Lead type and location
- Generator type
- Device model/serial numbers
- Fluoroscopy time (important for some payers)
- Procedural steps and confirmation of adequate thresholds
- Complications, if any
Global Period: 90 days
Any related follow-up or lead issues generally fall under the global unless unrelated.
ICD Implantation CPT Codes
ICDs require more complex documentation due to arrhythmia indications.
33249 – ICD system implantation (includes insertion of generator + at least one transvenous lead)
Used for:
- Single- or dual-chamber ICD systems
- Includes defibrillator testing when performed
For biventricular ICD (CRT-D), the codes differ:
33249 + lead placement codes for CRT-D:
- 33225 – LV (coronary sinus) lead insertion (add-on code)
Indications must include:
- Primary or secondary prevention of sudden cardiac death
- Ischemic or non-ischemic cardiomyopathy
- Documented EF criteria
- Failed medical therapy (for CRT-D)
Generator-Only Replacement
When the generator is replaced, but the leads remain intact:
Pacemaker Generator Change
- 33227 – Removal & replacement, single-chamber
- 33228 – Removal & replacement, dual-chamber
- 33229 – Removal & replacement, multi-chamber (CRT-P)
ICD Generator Change
- 33262 – ICD generator replacement, single-chamber
- 33263 – ICD generator replacement, dual-chamber
- 33264 – ICD generator replacement, multi-chamber (CRT-D)
Documentation must specify:
- Reason for generator change (battery depletion, elective replacement indicator)
- Existing leads and functionality
- Generator model numbers
- Lead testing performed
Important: Do not bill new lead placement unless a lead was truly replaced or repositioned.
Lead-Related Procedures
Lead Repositioning
- 33215 – Pacemaker or ICD lead repositioning (atrial or ventricular)
- 33226 – Left ventricular lead repositioning for CRT
Lead Repair
- 33218 – Pacemaker/ICD lead repair
Lead Replacement
- 33216 – Replacement of transvenous lead, single- or dual-chamber pacemaker
- 33217 – Replacement of transvenous lead, ICD
- Lead extraction is not covered by these codes.
Lead Extraction
Performed only with laser or mechanical extraction tools:
- 33244 – Pacemaker lead extraction
- 33243 – ICD lead extraction
Documentation must include:
- Reason for extraction (infection, malfunction, insulation failure)
- Tools used (laser sheath, mechanical sheath)
- Complication management details
Device Removal without Replacement
Pacemaker / ICD Removal
- 33233 – Removal of pacemaker generator
- 33234 – Removal of ICD generator
- Leads removed separately with extraction codes (33243, 33244).
Upgrades and System Conversions
Upgrades occur when moving from:
- Single → Dual chamber
- Dual → Biventricular (CRT-P)
- Pacemaker → ICD
- ICD → CRT-D
Billing typically includes:
- Lead insertion codes (33206/33207/33249 + add-on codes)
- Removal of the old generator
- New generator implantation
Example:
Upgrade from dual-chamber pacemaker → CRT-P
- 33228 – Remove/replace pacemaker generator
- 33225 – Insert LV lead
Documentation must explicitly state “upgrade” and clearly list each component performed.
Device Interrogation & Programming (In-Person)
Interrogation = Review only (no programming changes)
Pacemaker: 93288
ICD: 93289
Includes:
- Battery status
- Lead impedance
- Sensing/capture thresholds
- Measurements & stored electrograms
Programming = Active reprogramming + interrogation
Pacemaker: 93279–93281
ICD: 93282–93284
CRT-D/P: 93284
Interrogation vs programming rules:
- Both cannot be billed on the same day for the same device
- Programming requires documented parameter changes
Documentation must include:
- Specific settings assessed
- Any changes made
- Reason for the adjustment
- Post-programming measurements
Remote Monitoring Codes
Remote CIED monitoring is required by most payers for full compliance.
93294/93295 – Pacemaker remote monitoring
- 93294 = Professional review
- 93295 = Technical component
93296 – Technical component for other CIEDs (applies to ICD & CRT)
ICD Remote Monitoring: 93296 + 93297/93298
- 93297 – Professional ICD review
- 93298 – Professional CRT-D/P review
Billing rules:
- Typically, once every 30–90 days, depending on the payer
- Must have physician-documented analysis
- Must include clinically relevant interpretation
Remote monitoring denials often occur when:
- Documentation lacks interpretation
- Data appears auto-generated
- Transmission intervals are too short or too frequent
Global Periods for Pacemaker & ICD Procedures
Most implantations and major revisions carry a 90-day global period.
During the global:
- Routine follow-up is not separately billable
- Interrogation/programming may be bundled, depending on the payer
- Remote monitoring is usually still billable, but verify individually
E/M modifiers during global:
- 24 – Unrelated E/M
- 25 – Significant, separately identifiable E/M on the same day
- 57 – Decision for major surgery
Modifiers Used in Pacemaker & ICD Billing
Modifier 26 – Professional component
Applied for interpretation only (e.g., remote monitoring, interrogation).
Modifier TC – Technical component
Used by facilities for technical services.
Modifier 59/XS – Distinct procedural service
Common when:
- Lead repositioning is separate from generator change
- Multiple leads repaired or replaced
Modifier 78 – Return to OR for complication
Used when the patient returns to the cath lab/EP lab within the global to address a complication.
Modifier 79 – Unrelated procedure in global period
Example: A patient with a recent pacemaker placement requiring ICD placement unrelated to the original reason.
Documentation Requirements for Pacemaker & ICD Services
For Implantation:
- Indications (e.g., sinus node dysfunction, AV block, VT/VF history, cardiomyopathy)
- Pre-procedure evaluation
- Device and lead serial numbers
- Lead placements confirmed fluoroscopically
- Threshold, sensing, impedance details
- Defibrillator testing (if ICD)
- Post-procedure rhythm and hemodynamics
- Complication management
For Generator Changes:
- ERI/EOL battery documentation
- Functionality of existing leads
- Testing parameters
For Lead Work:
- Reason for reposition/replacement
- Imaging confirming placement
- Old and new lead measurements
For Interrogation/Programming:
- Device battery status
- Thresholds and impedance
- Stored arrhythmia events
- Programming adjustments and rationale
For Remote Monitoring:
- Clinically relevant interpretation
- Physician signature
- Data transmission summary
Common Denials & How to Avoid Them
1. Missing Medical Necessity Documentation
Especially for new implants, payers require proof of:
- Bradycardia
- Pauses
- VT/VF episodes
- EF criteria
2. Incorrect Use of Interrogation vs Programming Codes
Documented parameter changes must exist for programming.
3. Missing Device/Lead Serial Numbers
Required for implant, revision, and generator change billing.
4. Component Bundling Errors
Lead insertion and generator changes often trigger bundling edits.
5. Global Period Denials
Billing routine visits without modifiers 24/79 when appropriate.
6. Remote Monitoring Lacking Physician Interpretation
Auto-generated data alone is not sufficient.
7. Upcoding Lead Repositioning as Replacement
Leads must be removed and replaced for bill replacement.
Conclusion
Pacemaker and ICD billing is among the most complex billing domains in cardiology due to strict CPT bundling rules, documentation requirements, global period restrictions, and payer interpretations. Ensuring correct use of implantation codes, lead-related procedures, programming vs interrogation codes, and remote monitoring guidelines is essential for both compliance and accurate reimbursement. Practices may benefit from internal checklists and standardized documentation templates to avoid common audit risks. For teams needing structured support with CIED billing workflows, coding accuracy, or compliance reviews, expert firms such as Global Tech Billing LLC can assist.
FAQs
1. What CPT code is used for ICD implantation?
33249 is used for transvenous ICD implantation, with 33225 added for LV lead placement.
2. What is the difference between interrogation and programming?
Interrogation is review only; programming includes active parameter changes.
3. How often can remote monitoring be billed?
Every 30–90 days, depending on payer policy and device type.
4. When is generator replacement billed?
When the pulse generator reaches the elective replacement indicator or fails.
5. What is required for billing a lead replacement?
Removal of a malfunctioning lead and placement of a new one, with full documentation.
6. Can programming and interrogation be billed together?
No, only one may be billed per device per day.
7. What modifier is used for unrelated procedures during global?
Modifier 79.
8. Is fluoroscopy separately billable for pacemaker/ICD implants?
No, fluoroscopy is bundled into implantation codes.
