Summary & Overview
CPT 0413T: Removal of CCM Transvenous Atrial or Ventricular Electrode
CPT code 0413T denotes removal of an atrial or ventricular transvenous electrode used with a cardiac contractility modulation (CCM) system. This code captures a specialized device-explant procedure performed when CCM leads require extraction due to malfunction, infection, or system revision. As use of implantable cardiac devices expands, accurate coding for explantation procedures is important for clinical documentation, care coordination, and national utilization tracking.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication provides a national overview of coding context and clinical indications, payer coverage considerations, typical sites of service, and common procedural modifiers used with device removal services. It summarizes benchmarking and policy-relevant points that affect billing and claims submission for explantation of CCM transvenous electrodes.
Readers will learn what CPT code 0413T represents, the clinical and procedural context for electrode removal, expected care settings, and the types of information payers commonly evaluate during claims review. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 0413T describes removal of an atrial or ventricular transvenous electrode used with a cardiac contractility modulation (CCM) system. The procedure involves explanting an electrode that transmits and receives electrical impulses and is typically connected to the end of an insulated lead.
-
Service type: Device explantation / lead removal
-
Typical site of service: Hospital inpatient or outpatient surgical setting, or ambulatory surgical center
Clinical & Coding Specifications
Clinical Context
A 68-year-old patient with ischemic cardiomyopathy and symptomatic heart failure with reduced ejection fraction (HFrEF) previously implanted with a cardiac contractility modulation (CCM) device presents for elective removal of the transvenous atrial or ventricular electrode due to lead malfunction, pocket infection, lead fracture, or system upgrade. Pre-procedure workflow includes device interrogation, chest radiography, review of anticoagulation and infection status, informed consent, and coordination with electrophysiology and cardiothoracic surgery teams for backup if extraction is complex. The procedure is typically performed in an electrophysiology laboratory or operating room under conscious sedation or general anesthesia with fluoroscopic guidance. Post-procedure workflow includes hemostasis, wound care, device interrogation (if remaining components), antibiotic therapy when indicated, and post-procedure monitoring for complications such as bleeding, pneumothorax, cardiac tamponade, or arrhythmia. Typical site of service is an inpatient or outpatient hospital-based electrophysiology lab or operating room. The service type is a procedure for removal of a transvenous electrode component of a CCM system, billed per lead removal using 0413T.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | When reporting physician professional interpretation or professional services separate from technical facility charges |
51 | Multiple procedures | When multiple distinct procedures are performed during the same encounter |
52 | Reduced services | When the service provided is partially reduced or eliminated at the physician's discretion |
53 | Discontinued procedure | When the procedure is terminated due to extenuating circumstances or those that threaten patient safety |
62 | Two surgeons | When two surgeons work together as primary surgeons performing distinct portions of the procedure |
66 | Surgical team | When a surgical team approach is required for complex extraction |
78 | Return to the operating room for a related procedure during the postoperative period | When the patient requires a return to the OR for a complication related to the original procedure |
80 | Assistant surgeon | When an assistant surgeon is required and not reported under a different modifier |
81 | Minimum assistant surgeon | When a minimum level of assistance is provided by an assistant surgeon |
82 | Assistant surgeon (when qualified resident surgeon not available) | When an assistant surgeon is required because a qualified resident is not available |
73 | Discontinued outpatient hospital/ambulatory surgery before anesthesia | If the outpatient procedure is cancelled after patient prepared but before anesthesia |
53 | Discontinued procedure | (Listed intentionally only once for clarity) |
TC | Technical component | When the facility bills only the technical component of a service |
QK | Medical direction of two, three, or four services or procedures involving the same physician assistant/NP/clinical nurse specialist | When a physician directs midlevel providers during performance of services |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
207RH0000X | Cardiovascular Disease (Cardiology) | Electrophysiologists and cardiologists manage CCM systems and lead removal decisions |
207T00000X | Thoracic Surgery | Cardiothoracic surgeons provide backup for complex extractions or surgical removal |
2084P0800X | Cardiac Electrophysiology | Electrophysiology specialists perform the extraction with fluoroscopic guidance |
363A00000X | Anesthesiology | Anesthesiologists provide sedation or general anesthesia for patient comfort and safety |
208800000X | Internal Medicine (Hospitalist) | Hospitalists manage perioperative medical comorbidities and inpatient care |
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
I50.22 | Chronic systolic (congestive) heart failure | CCM devices are used in patients with HFrEF; lead removal may be required for malfunction or infection |
I50.32 | Chronic diastolic (congestive) heart failure | Alternative heart failure phenotype in patients who may have CCM therapy considerations |
I42.0 | Dilated cardiomyopathy | Underlying cardiomyopathy often coexists with indications for CCM and may necessitate lead management |
T82.7XXA | Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter | Pocket or lead infection is a common indication for lead removal |
T82.3XXA | Mechanical complication of cardiac device, initial encounter | Lead fracture, insulation break, or malposition leading to elective removal |
I25.10 | Atherosclerotic heart disease of native coronary artery without angina pectoris | Common comorbidity in patients with ischemic cardiomyopathy receiving CCM therapy |
Z45.0 | Adjustment and management of pacemaker [device] | Encounter for adjustment, replacement, or removal of cardiac device components |
Z98.890 | Other specified postprocedural states | Status post device implantation or prior procedures relevant to current extraction |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
33233 | Removal of pacemaker or cardioverter-defibrillator lead(s) — transvenous; single lead | Similar lead removal technique; may be used when leads are part of a pacemaker/ICD system rather than a CCM-specific lead |
33234 | Removal of pacemaker or cardioverter-defibrillator lead(s) — transvenous; two leads | Relevant when more than one transvenous lead requires removal during the same encounter |
33235 | Removal of pacemaker or cardioverter-defibrillator lead(s) — transvenous; extraction, transvenous, with specialized tools | Used for complex extractions requiring extraction tools and greater resources |
33212 | Removal of pacemaker pulse generator with or without replacement | Performed when the CCM pulse generator or other pulse generators are removed or replaced in conjunction with lead removal |
33216 | Insertion of new transvenous single lead pacemaker system; with or without removal of existing system | Relevant when lead removal is followed by implantation of a replacement lead or device |
33228 | Insertion of epicardial lead(s) | May be performed if transvenous access is not feasible and an alternative lead approach is required |