CPT® Code 33280

Official Description

Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator only

Common Language Description

The procedure described by CPT® Code 33280 involves the removal of a phrenic nerve stimulator, specifically focusing on the pulse generator component of the neurostimulator system. This system is primarily utilized in the treatment of central sleep apnea (CSA), a condition that can significantly impact a patient's quality of life. The removal process is intricate due to the typical patient profile, which often includes individuals with heart failure and reduced ejection fraction. These patients may have leads positioned in critical vascular structures such as the brachiocephalic or pericardiophrenic vein, which heightens the risk of vascular or cardiac complications during the procedure. The neurostimulator system itself comprises an implantable pulse generator, a stimulation lead, and occasionally a pressure-sensing lead located in the azygos vein. The removal of the pulse generator is generally performed under general anesthesia, and it may involve the extraction of one lead as well. While it is uncommon to remove only a lead or only the generator, there are specific circumstances where this may occur. For instance, a generator may be extracted prior to other treatments like radiation therapy, while a lead may need to be removed if it becomes infected or cannot be extracted simultaneously with the pulse generator. During the procedure, the surgeon establishes the position of the pulse generator and makes an incision to access the device, which is typically located in a subcutaneous pocket. The generator and any attached lead(s) are meticulously freed from the surrounding tissue, and the leads are disconnected from the generator. If necessary, a stylet or stiff guidewire is utilized under fluoroscopic guidance to facilitate the removal of the lead. In cases where the lead is not easily removable, advanced techniques such as the use of a locking stylet and a manual rotational extractor or laser sheath may be employed. The procedure concludes with the removal of the generator and lead(s), ensuring hemodynamic stability before closing the incision. If only the pulse generator is removed, any abandoned lead(s) are left in place, while the removal of a lead involves similar careful disconnection and extraction techniques.

1. Indications

The removal of a phrenic nerve stimulator, as described by CPT® Code 33280, is indicated for patients undergoing treatment for central sleep apnea (CSA). The procedure may be necessary in specific scenarios, including:

Heart Failure with Reduced Ejection Fraction Patients with heart failure and reduced ejection fraction may require the removal of the stimulator due to complications or changes in their treatment plan.
Infection A lead may need to be removed if it becomes infected, necessitating intervention to prevent further complications.
Pre-treatment Preparation The pulse generator may be removed prior to other treatments, such as radiation therapy, to ensure patient safety and treatment efficacy.
Device Malfunction If the neurostimulator system is malfunctioning or not providing the intended therapeutic benefit, removal may be warranted.

2. Procedure

The procedure for the removal of a phrenic nerve stimulator involves several critical steps, which are detailed as follows:

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 The surgeon identifies the location of the pulse generator, which is typically situated in a subcutaneous pocket. An incision is made to access this area, allowing for direct visualization of the device.
Step 3: Disconnection of Leads Once the generator is exposed, the surgeon carefully frees the generator and any attached lead(s) from surrounding tissue. The leads are then disconnected from the generator, ensuring that all connections are properly managed.
Step 4: Lead Extraction If a lead is to be removed, 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 proves difficult to extract, a locking stylet may be utilized, and a manual rotational extractor or laser sheath is advanced over the lead to assist in its removal.
Step 5: Hemodynamic Stability After the generator and lead(s) are successfully removed, the surgical team ensures that the patient maintains hemodynamic stability before proceeding to close the incision.
Step 6: Closure The incision is then closed in layers, ensuring proper healing and minimizing the risk of complications.

3. Post-Procedure

Post-procedure care following the removal of a phrenic nerve stimulator is essential for patient recovery. Patients are typically monitored for hemodynamic stability and any signs of complications, such as infection or bleeding. Pain management is provided as needed, and patients may be advised on activity restrictions to promote healing. Follow-up appointments are scheduled to assess recovery and address any concerns that may arise after the procedure. If only the pulse generator was removed, the abandoned lead(s) are left in place, and their status will be monitored during follow-up visits.

Short Descr	RMVL PHRNC NRV STIM PG ONLY
Medium Descr	RMVL PHRENIC NRV STIMULATOR PULSE GENERATOR ONLY
Long Descr	Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator 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	Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight.
Type of Service (TOS)	2 - Surgery
Berenson-Eggers TOS (BETOS)	none
MUE	1

Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).

Requirements specified in the medical policy have been met