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Tag Archives: Atrial

Help!!! Attempted upgrade of dual-chamber pacemaker to atrial synchronous biv

Posted on by
Hi – Happy New Year!!!!

We’re having a problem with this op report as the provider would like to separate the radiology codes from the attempted biv insert. We believe the radiology codes are included. Can someone please either confirm or advise whether they are or are not included so we can advise our provider again. Many thanks!!!!

CPT Codes to bill:

33249-52
75827, 26
75820, 26
75860, 26
93280, 26

PROCEDURES PERFORMED:
1. Attempted upgrade of dual-chamber pacemaker to an atrial synchronous
biventricular cardioverter-defibrillator.
2. Interrogation and reprogramming of a dual-chamber pacemaker.
3. Peripheral angiography of the upper extremity as well as subclavian and
superior vena cava.

INDICATION: gentleman with a history of a
cardiomyopathy, left ventricular systolic function of approximately 25% with
New York Heart Association classification 3. Heart failure with chronically
right ventricular pacing, who is referred at this time for upgrade of his dual-
chamber pacemaker to an atrial synchronous biventricular cardioverter-
defibrillator.

PROCEDURE IN DETAIL: The patient was brought to electrophysiology laboratory
in a fasting postabsorptive state. Informed written consent was obtained.
Vancomycin 1 g IV was administered prior to the procedure. The patient was
prepped and draped in the usual sterile fashion. 1% bupivacaine was
infiltrated into the left deltopectoral region. An incision was made over the
existing pacemaker generator and the existing pacemaker (make Biotronik) was
removed from the pocket. Subsequently, utilizing a standard Seldinger
technique, an 18-gauge needle was inserted into the left subclavian vein under
fluoroscopic guidance. A guidewire was subsequently advanced to the region of
the inferior vena cava under fluoroscopic guidance. Similarly utilizing
standard Seldinger technique, a 2nd 18-gauge needle was inserted into the left
subclavian vein under fluoroscopic guidance. The guidewire was also advanced
to the region of the inferior vena cava under fluoroscopic guidance. Through
the first guidewire, a 9.5-French sheath was subsequently inserted into the
left subclavian vein under fluoroscopic guidance. The coronary sinus sheath
was subsequently advanced under fluoroscopic guidance; however, resistance was
met at the juncture of the innominate vein and the superior vena cava. A Swan
wire was attempted to be placed over the Swan-Ganz catheter that was within
the coronary sinus guide, which again could not be advanced past this area.
Subsequently, intravenous contrast was injected into the subclavian vein and
superior vena cava region demonstrating occlusion of the superior vena cava at
close to the juncture of the connection between the SVC and the right atrium.
There was some extravasation of contrast suggestive of possible SVC
dissection. At this point, given the fact that the patient was anticoagulated
and there was no evidence of distal flow, it was decided to abort the
procedure. Further fluoroscopic evaluation had demonstrated that the contrast
indeed was able to flow via collaterals to the right atrium. There was no
further evidence of dissection nor SVC rupture. The patient remained
hemodynamically stable. A 2D echocardiogram was performed in the cath lab,
which demonstrated no evidence of pericardial effusion.

The patient was subsequently returned to the intensive care unit for further
monitoring. Serial H and H were drawn every 2 hours to monitor the patient
carefully.

IMPRESSION: Aborted upgrade of a pacemaker to an atrial synchronous
biventricular cardioverter-defibrillator due to SVC occlusion.

PLAN: Plan is to observe the patient on telemetry in the ICU. We will
continue to monitor H and H’s carefully. Do a followup chest x-ray to rule
out any evidence of hemothorax. The chest x-ray performed immediately after
the procedure demonstrated no evidence of hemothorax. Eventually, once this
heals, we may consider performing peripheral angiography from the right side
to see if there is any patency from the right side through the SVC into the
right atrium. If indeed there is, then we will proceed with implantation of
an atrial synchronous biventricular cardioverter-defibrillator from the right
subclavian approach. I discussed this at length with the patient as well as
his family and all questions were answered in detail.

Many thanks :)
Jane

Medical Billing and Coding Forum

LT or RT direct atrial catheter placement and RT and LT catheter placement

Posted on by
Help with pediatric CVT coding…surgeons are placing atrial catheters directly into the atrium (usually through the appendage) at the end of a complex surgical procedure. This can be on the RT or LT and sometimes both RT and LT. The codes the surgeons are submitting for billing are 36555 or 36013. Those do not seem correct. What is the correct way to code for each, RT, LT and for both RT and LT. Please help.

Thank you

Medical Billing and Coding Forum

Wachman left atrial appendage occlusion device implantation with EXTRAS

Posted on by
Hi,
Looking for any help with this procedure. It’s a watchman implantation however our Provider would like to add a little extra to it and I’m not sure if that is possible. Looking for any advice……

REASON FOR PROCEDURE: Paroxysmal atrial fibrillation, hematuria on
anticoagulation.

PROCEDURES:
1. Transesophageal echocardiogram with 2D echo, M-mode Doppler, and color
flow mapping.
2. Watchman left atrial appendage occlusion device implantation.
3. Arterial catheter placement.
4. Venous catheter placement.

HARDWARE:
1. Boston Scientific Watchman access system sheath, double curve, 14-French,
lot #21482043.
2. Boston Scientific watchman 24 mm device, lot #21485158.

DESCRIPTION OF PROCEDURE: Informed consent was obtained from the patient,
signed, and placed on the chart. He seemed to understand the risks, benefits,
and alternatives and agreed to proceed. The patient was brought to the
cardiac electrophysiology lab in a fasting state and placed supine on the
fluoroscopy table. General endotracheal anesthesia was administered and
supervised by the Anesthesiology staff. The right groin was prepped with
ChloraPrep and draped in the usual sterile fashion. A bite block was placed,
and this was also draped in sterile fashion. The TEE probe was inserted
through a sterile sleeve, and then inserted into the esophagus without
difficulty.

The transesophageal echocardiography was performed. In the 0, 45, 90, and 135
degrees angles, the appendage ostial width was 15.5 mm, 13 mm, 15 mm, and 17.0
mm, and the length was 25 mm, 18 mm, 17 mm, and 16 mm.

The skin of the right groin was anesthetized with 1% lidocaine local, followed
by the deeper structures. Using the modified Seldinger technique, an 8-French
25 cm sheath, an 8.5-French SL1 sheath were placed in the right common femoral
vein, and a 4-French 11 cm sheath was placed in the right common femoral
artery. All sheaths were aspirated and flushed. Pressure tubing was
connected to the arterial sheath and was handed to the anesthesiologist for
invasive hemodynamic monitoring.

Heparin was given with an additional dose of 15000 units, with repeated bolus
was given to maintain an ACT of greater than 300 seconds.

Under fluoroscopic guidance, the wire in the SL1 sheath was advanced to the
superior vena cava, and the sheath and dilator were advanced over the wire.
The wire was removed, the dilator was flushed, and a flushed Baylis needle was
advanced through the dilator. The dilator, needle, and sheath were withdrawn
under fluoroscopic guidance to the fossa ovalis. Tenting was visualized on
transesophageal echocardiography. The fossa ovalis was small. Once a
suitable location was found, radiofrequency energy was applied and a
transseptal puncture was performed. The needle was flushed, and micro bubbles
were seen in the left atrium as expected. A left atrial pressure waveform was
noted, and the mean left atrial pressure was 17 mmHg.

The dilator was advanced over the needle, and the sheath was advanced over the
dilator. The dilator and needle were slowly withdrawn, and bright red blood
was aspirated from the sheath. The sheath was carefully flushed. An Amplatz
Super Stiff wire was then advanced through the sheath into the left superior
pulmonary vein, and the sheath was exchanged over the wire for a double curve
14-French Watchman access system sheath and dilator.

Once the dilator was in the left atrium, the sheath was advanced over the
dilator and wire, and then the dilator and wire were withdrawn. The sheath
was carefully aspirated and flushed. A flushed 5-French straight pigtail
catheter was advanced through the sheath into the left atrium. The pigtail
catheter was aspirated and flushed. It was inserted into the anterior lobe of
the left atrial appendage, and angiogram of the appendage was recorded using
hand injection of contrast.

The sheath was advanced over the pigtail catheter up to the 24 mm depth
marker. The Watchman 24 mm device was carefully prepared and flushed. The
pigtail catheter was withdrawn, and the Watchman delivery catheter was
inserted through the sheath until the distal markers aligned. The sheath was
then withdrawn to expose the end of the catheter. During apnea, the sheath
was withdrawn to deploy the device in the left atrial appendage ostium.

A tug test was performed, and the device was in stable position. Followup
measurements using TEE were recorded, with measurements at 0, 45, 90, and 135
degrees of 18.6 mm, 17.5 mm, 16.6 mm, and 18.6 mm. This yielded compressions
of 22% to 31%. Color-flow Doppler and injection of contrast through the
sheath showed no residual leak surround the device.

The threaded rod was unscrewed to release the device. IV protamine was given.
The sheath and dilator were removed under fluoroscopy to avoid dislodging
leads. A suture was tied around the insertion site in the groin using #2
Vicryl. Transesophageal echocardiography was performed to rule out
postprocedure pericardial effusion.

After protamine was given, the sheaths were removed, and hemostasis was
obtained with manual compression with tightening the suture. The patient was
successfully extubated and transferred to the PACU.

CPT CODES: 33340 Q0
ICD 10: I48.0, Z00.6
Clincial trial number etc.
As far as the interoperative Tee is concerned, according to the Boston Scientific Guide Point Reimbursement Resources, this can only be charged by a separate individual who is not performing the interventional procedure with CPT 93355.
Our Provider would also like to charge for Arterial Catheter Placement and Venous Catheter Placement; CPT 93503? and 36010? I’m not sure about these codes but I thought they were included in.

Any help will do for information I can provide my provider as to why certain codes cannot be charged while doing a Watchman.

Many thanks,

Jane:)

Medical Billing and Coding Forum

Atrial baffle procedure (non-Mustard, non-Senning)

Posted on by
Help!! I am crossing every single finger and toe that someone here has had to code this
procedure. It’s a rare birth defect, so the procedure isn’t one that performed frequently.

From the op report:

PROCEDURE:
1. Left superior vena cava baffling towards the right atrium.
2. ASD closure with a fresh pericardial patch.

Description of Procedure:
… the TEE was done that confirmed the diagnosis of a very large ASD with absent
of the IVC drain and also confirmed the diagnosis of left superior vena cava arising
to the dome of the left atrium without bridging innominate vein. After opening
the chest, the thymus was fully dissected. Then a large piece of pericardium was
harvested and the rest of the pericardium was marsupialized. The pursestring was
done in the ascending aorta and right superior vena cava, left superior vena cava
and inferior vena cava. A pursestring was done in the right upper pulmonary veins.
Then the patient was heparinized and was cannulated in the usual fashion and
cardiopulmonary bypass was initiated at 32 degrees Celsius. A plegia needle was
placed in the ascending aorta and LA vent was placed in the right superior pulmonary vein.
Right and left SVC snuggers were placed and tied down. Next, the aorta was
crossclamped and needle cardioplegia was antegrade infused and the patient had
good cardiac arrest. The IVC snuggers was tied down and the right atrium was
opened and stay sutures were placed on the edges of the atrium for better
visualization. Inside the heart, a large ostium secundum ASD was visualized
with a complete absence of the IVC rim Then the left superior vena cava was
visualized that was arising to the dome of the left atrium. In order to repair
this kind of congenital malformation, a large piece of autologous pericardium
was harvested and it was used to baffle the left superior vena cava with a 5-0
C1 Prolene running suture line. The first stitch was placed in the tissue
between the left superior vena cava and the left atrial appendage and that
suture line was carried out toward the anterior close to the mitral annulus on
the left side and then anterior, close to the right superior vena cava on the
right side. Then this pericardial patch was turned and baffled inferior,
posterior toward the direction of the IVC. In that way, both arterial rims
were taken with this pericardial patch. Once finalized, the LSVC was baffling
with a single pericardial patch toward the right atrium and with the same
single pericardial patch the ASD was closed. After closing the ASD and
baffling the LSVC. The LA vent was stopped and the heart was de-aired and the
aortic crossclamp was removed, recovering the patient with normal sinus rhythm.

I was able to find a more straight-forward description of this procedure in an old
issue of The Annals of Thoracic Surgery (circa 1986!!):
Repair of Left Superior Vena Cava Entering the Left Atrium

ABSTRACT Connection of an anomalous left superior
vena cava to the left atrium is an uncommon lesion that is
usually associated with other complex intracardiac malformations.
A technique for diverting the anomalous caval
return along the left atrial roof and into the right atrium is
presented. This simple tunnel method avoids potential obstruction
to systemic and pulmonary venous return and
leaves viable atrial tissue comprising the majority of the
new pathway… We present an alternative method of
repair that consists of constructing a tunnel along the roof
of the left atrium, thereby diverting the anomalous caval
return into the right atrium. This simple method leaves
viable atrial wall comprising the majority of the new
pathway.

SO… my provider is suggesting we use 33774 (Repair of transposition of the great arteries,
atrial baffle procedure (eg, Mustard or Senning type) stating that it was a modified
Mustard procedure. I want to agree, but the only similarities between the CPT code and his op rpt
is the baffle/tunnel that was created. Other options I have suggested include 33999 (unlisted cardiac)
or 34502 (repair of vena cava, any method). The ASD repair will be billed in addition to this code.

Am I missing a more obvious choice for this procedure? (it feels like I am…)

If you’ve made it to this point, bless you… :)

Andrea T Williams, CPC

Medical Billing and Coding Forum