CPT® Code 33279

Official Description

Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sensing lead(s) only

Common Language Description

The procedure described by CPT® Code 33279 involves the removal of a phrenic nerve stimulator system, which is specifically utilized in the treatment of central sleep apnea (CSA). This procedure is complex due to the typical patient profile, which often includes individuals with heart failure and reduced ejection fraction. The leads of the stimulator are usually positioned in critical vascular structures such as the brachiocephalic or pericardiophrenic vein, which increases the risk of potential vascular or cardiac damage during the removal process. The neurostimulator system itself comprises an implantable pulse generator, a stimulation lead, and, in some cases, a pressure-sensing lead that may be located in the azygos vein. The removal procedure is performed under general anesthesia to ensure patient comfort and safety. It typically involves the extraction of the pulse generator along with one lead, although instances of removing only a lead or solely the generator are rare. The removal of the generator may be indicated prior to other treatments, such as radiation therapy, while a lead may need to be extracted if it is infected or cannot be removed simultaneously with the pulse generator. The surgical approach begins with establishing the position of the pulse generator, followed by making an incision to access the previously implanted device located in its subcutaneous pocket. The generator and lead(s) are meticulously freed from the surrounding tissue to facilitate their removal. This procedure requires careful handling to avoid complications and ensure the safety of the patient throughout the process.

1. Indications

The procedure described by CPT® Code 33279 is indicated for the removal of a phrenic nerve stimulator system in patients diagnosed with central sleep apnea (CSA). The following conditions may warrant this procedure:

Central Sleep Apnea (CSA) - A condition where the brain fails to send appropriate signals to the muscles that control breathing, necessitating the use of a phrenic nerve stimulator.
Heart Failure - Patients with heart failure may require the removal of the stimulator due to complications or changes in their treatment plan.
Reduced Ejection Fraction - Individuals with a reduced ejection fraction may present additional risks during the removal process, making careful evaluation necessary.
Infection - If a lead becomes infected, it may necessitate its removal to prevent further complications.
Inability to Remove Simultaneously with Generator - In cases where the lead cannot be removed at the same time as the pulse generator, a separate procedure may be required.

2. Procedure

The procedure for the removal of the phrenic nerve stimulator system involves several critical steps to ensure safety and effectiveness:

Step 1: Anesthesia Administration - The procedure begins with the administration of general anesthesia to ensure the patient is comfortable and pain-free throughout the operation.
Step 2: Incision and Access - An incision is made to access the subcutaneous pocket where the pulse generator is implanted. This step is crucial for exposing the device for removal.
Step 3: Disconnection of Leads - The generator and lead(s) are carefully freed from surrounding tissue. The leads are then disconnected from the generator, and any suture collars holding them in place are also released.
Step 4: Lead Extraction - A stylet or stiff guidewire is inserted onto the lead under fluoroscopic guidance. Gentle manual traction is applied to facilitate the lead's removal. If the lead is not easily removable, a locking stylet is inserted, and a manual rotational extractor or laser sheath is advanced over the lead to assist in extraction.
Step 5: Hemodynamic Stability - After the generator device and lead(s) are removed, the surgical team ensures that hemodynamic stability is achieved before proceeding to close the incision.
Step 6: Closure - The incision is closed following the removal of the device(s), ensuring that any abandoned lead(s) are disconnected and left in position if the pulse generator alone is removed.

3. Post-Procedure

Post-procedure care following the removal of the phrenic nerve stimulator system is essential for patient recovery. Patients are typically monitored for hemodynamic stability and any signs of complications, such as infection or bleeding. Pain management strategies are implemented to ensure patient comfort. Recovery time may vary based on individual patient factors, but patients are generally advised to follow up with their healthcare provider to assess the surgical site and overall recovery progress. Instructions regarding activity restrictions and signs of potential complications are provided to ensure a safe recovery process.

Short Descr	RMVL PHRNC NRV STIM TRANSVNS
Medium Descr	RMVL PHRNC NRV STIMULATOR TRANSVNS STIMJ/SNSG LD
Long Descr	Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sensing lead(s) only
Status Code	Active Code
Global Days	090 - Major Surgery
PC/TC Indicator (26, TC)	0 - Physician Service Code
Multiple Procedures (51)	2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50)	0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62)	0 - Co-surgeons not permitted for this procedure.
Team Surgery (66)	0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Hospital Part B services paid through a comprehensive APC
ASC Payment Indicator	Device-intensive procedure added to ASC list in CY 2008 or later; paid at adjusted rate.
Type of Service (TOS)	2 - Surgery
Berenson-Eggers TOS (BETOS)	none
MUE	1

Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.