How To Use CPT Code 0416T

CPT 0416T describes the relocation of a skin pocket for an implanted cardiac contractility modulation pulse generator. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples of CPT code 0416T.

1. What is CPT Code 0416T?

CPT 0416T can be used to describe the relocation of a skin pocket for an implanted cardiac contractility modulation pulse generator. This code is used when a provider creates a new pocket in a different location and moves the pulse generator to the new pocket.

2. Official Description

The official description of CPT code 0416T is: ‘Relocation of skin pocket for implanted cardiac contractility modulation pulse generator.’

3. Procedure

1. In preparation for the procedure, the existing and planned pocket sites are prepped.
2. The patient may be sedated, and local anesthesia is administered.
3. The physician opens the healed incision over the pulse generator and removes any scar tissue.
4. The leads are tested and the site and generator are inspected.
5. An incision is made in the subcutaneous tissue, typically in the opposite side of the chest or upper abdominal wall, to create a new pocket for the generator.
6. If necessary, additional anesthesia is administered to allow the provider to place lead extenders to the new pocket.
7. The leads and generator are connected and placed in the new pocket, which is then closed.
8. The old pocket is addressed to prevent infection and ensure healing.

4. Qualifying circumstances

CPT 0416T is used when a patient already has a skin pocket for a pulse generator component of a cardiac contractility modulation (CCM) system and the provider needs to create a new pocket in a different location and relocate the pulse generator. The CCM system consists of a pulse generator and three electrodes that deliver electrical impulses to increase the strength of contractility in patients with persistent congestive heart failure not responding to optimal medical therapy.

5. When to use CPT code 0416T

CPT code 0416T should be used when a provider needs to relocate the skin pocket for an implanted cardiac contractility modulation pulse generator. It should only be reported for the relocation of the skin pocket and not for other components or procedures related to the CCM system.

6. Documentation requirements

To support a claim for CPT code 0416T, the provider must document the following information:

• Patient’s diagnosis and the need for the relocation of the skin pocket
• Details of the procedure, including the sites of the existing and planned pockets
• Date of the procedure
• Any additional anesthesia administered
• Details of the closure of the new pocket and addressing of the old pocket
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 0416T, ensure that the procedure involves the relocation of the skin pocket for the implanted cardiac contractility modulation pulse generator. It should not be reported with other codes related to the CCM system. Always check with the payer regarding their policies on the coverage and reimbursement of the CCM system and associated procedures.

8. Historical information

CPT code 0416T was added to the Current Procedural Terminology system on January 1, 2016. There have been no updates to the code since its addition.

9. Examples

1. A physician relocates the skin pocket for an implanted cardiac contractility modulation pulse generator from the chest to the upper abdominal wall in a patient with persistent congestive heart failure.
2. A surgeon creates a new pocket in the opposite side of the chest and moves the pulse generator for a patient with a CCM system.
3. A cardiologist performs the relocation of the skin pocket for an implanted cardiac contractility modulation pulse generator in a patient who requires a change in the location of the pulse generator.
4. An electrophysiologist moves the pulse generator to a new pocket in the upper abdominal wall for a patient with a CCM system.
5. A cardiac surgeon relocates the skin pocket for an implanted cardiac contractility modulation pulse generator in a patient with persistent congestive heart failure who needs a new pocket location.
6. A provider performs the relocation of the skin pocket for an implanted cardiac contractility modulation pulse generator in a patient who requires a different pocket location due to complications.
7. An interventional cardiologist moves the pulse generator to a new pocket in the chest for a patient with a CCM system.
8. A cardiac electrophysiologist relocates the skin pocket for an implanted cardiac contractility modulation pulse generator in a patient with persistent congestive heart failure who needs a change in the pocket location.
9. A surgeon creates a new pocket in the upper abdominal wall and moves the pulse generator for a patient with a CCM system.
10. A cardiologist performs the relocation of the skin pocket for an implanted cardiac contractility modulation pulse generator in a patient who requires a different pocket location for optimal therapy.