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Attempted Bi-V Pacemaker – Only one active lead – Please HELP!!!

Can someone please help! He placed a bi-v generator and RV lead. He plugged the atrial port and isn’t planning to place an atrial lead. He is planning to come back in 4-6 weeks to place the LV lead.
The patient will ultimately be left with a bi-v generator and active RV and LV leads but for now the patient essentially has one active lead.

Any help is MUCH appreciated!!!

PREPROCEDURE DIAGNOSES:
1. Atrial fibrillation.
2. Rapid ventricular response.
3. Tachymedia.
4. Cardiomyopathy.

POSTPROCEDURE DIAGNOSES:
1. Atrial fibrillation.
2. Rapid ventricular response.
3. Tachymedia.
4. Cardiomyopathy.

PROCEDURE: Attempted Bi-V pacemaker implant but complicated by dissection of the CS.

PROCEDURE COURSE: Mrs. Young presented to the EP lab in the fasting state. She was in AFib with RVR. The procedure was performed under conscious sedation with the assistance of our anesthesia colleagues. She was administered 2 grams of Ancef prior to the start of the case. After the huddle, she was prepped and draped in usual sterile fashion. After the timeout, a pocket was created in the left subclavian space using a blade, blunt dissection and electrocautery. After hemostasis was achieved in the pocket, using the 1st rib approach, venous access was obtained x 2 over the first guidewire, a 7-French tear-away sheath was placed in the SVC. Through this lead, an MRI compatible Medtronic pace is 5076 lead was advanced into the RV apical septum and the helix was extended despite yielded excellent pacing and sensing parameters with sensing of 14 millivolts and capture threshold of 0.25 volts with a pacing impedance of 532. The sheath was removed and the lead was tied down to the pectoralis fascia with nonabsorbable suture. Over the second guidewire, a 9 French sheath was placed and through this a straight Attain and a Josephson catheter and this was unable to cannulate the CS. Then, we used a medium hook Attain and this too was unable to cannulate the CS and then we used the larger hook Attain and this was able to finally get access into the CS. It was difficult as it was a fairly posterior takeoff but got access that was not overly difficult; however, upon advancing the sheath noted that in placing the sheath in the CS. Then, with a balloon tipped catheter, a venogram of the CS was performed showing that we had dissected the CS. I did try to pass a wire, but it was never in the true lumen and was unable to place a guidewire. She remained hemodynamically stable through this. Given this and I now have an idea of where the CS was located. I think that the best course of action will be to bring her back in approximately 4-6 weeks and place an LV lead at that time and do the AV node ablation. The 9-French sheath was removed and hemostasis achieved with manual pressure. The pocket was then cleansed with vancomycin solution and then a BiV pacemaker was used to plug in the atrial port as there was no plan in putting an atrial lead given that she has now permanent atrial fibrillation. The LV lead port was plugged and the RV pace sense lead was attached to the device and the device and leads were placed into the pocket. Pocket was then closed in 3 layers with absorbable suture. Device check confirmed appropriate capture and sensing of the RV lead then Steri-Strips and dry sterile dressing were placed over the wound. Mrs. Young tolerated the procedure well without apparent complications. A chest x-ray will be obtained tonight. Plan will be to return in approximately 4-6 weeks for addition of an LV lead at that time and AV node ablation. She is set up at VVI 50.

Medical Billing and Coding Forum

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

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

Attempted Port Placement

Needle access into remnant of right and left IJ under ultrasound
guidance for attempted port placement. Informed consent was obtained from the patient for port placement.
Ultrasound evaluation however showed what appeared to be some remnant of
internal jugular veins bilaterally. Under ultrasound guidance first the
right, then the left remnant of the internal jugular vein was cannulated
. A
wire, however, was unable to be placed centrally from either location.
Patient with history of previous neoplastic disease and radiation therapy.
Case was discussed with Dr. X’s nurse. Formal vascular ultrasound
evaluation may be useful for further evaluation of the patency or occlusion
of the central venous system. Access from the common femoral vein may be
attempted if no other suitable site is found/available
The patient tolerated this procedure will no evidence of immediate
complications.
Should I report 36561-53 or maybe 36011-50?
Thanks for any guidance :)

Medical Billing and Coding Forum

Bladder Neck Contracture Dilation / attempted contracture incision

Looking for some advice on the following:

PREOPERATIVE DIAGNOSIS: Bladder neck contracture.

POSTOPERATIVE DIAGNOSIS: Bladder neck contracture.

OPERATION: Cystoscopy, bladder neck dilation, Foley placement,
attempted bladder neck incision.

INDICATIONS FOR SURGERY:
The patient has a history of TURP in the past with bladder neck contracture and hematuria. The patient also has obstructive urinary symptoms, comes in for bladder neck incision,
ended up with dilation,
see below.

DESCRIPTION OF OPERATION:
The patient was identified in the waiting room and brought into the
OR. Preoperative antibiotics were provided. Anesthesia was
administered. The patient was placed in lithotomy position, then
prepped and draped in a standard sterile surgical fashion. Time-out
was performed. Consent was verified. Next, a 19-French cystoscope
with a 30-degree lens was inserted into the urethra. No strictures
in the anterior urethra. Prostatic fossa appeared open. The
bladder neck was very tight and contracted. I could not easily pass
the scope. Next, a Sensor wire was passed through the scope into
the bladder. The scope was removed. Next, I decided to dilate the
bladder neck a little bit so I can pass the urethra tome with the
Collins knife using blue plastic dilators. I slowly dilated the
bladder neck from size 18 to size 24, which was the biggest dilator
I had. The Collins knife was only available to use with the
26-French sheath and obturator. I removed the wire and slowly tried
to pass the 26 sheath with an internal obturator. I did meet some
resistance at the bladder neck. I then stopped. Inserted a camera.
I could see the bladder neck opening, but also the patient appeared
to have a false passage to the right side at the level of the
prostate. I then decided to just leave a Foley catheter.
Again, I
placed a 19-French scope, passed a wire into the bladder. I again
passed a dilator. The 24-French dilator passed easily into the
bladder without resistance. A 22-French Council tip Foley catheter
was then passed over the wire into the bladder. Balloon inflated
with 15 mL of sterile water. Urine output was clear. No hematuria
was noted. The patient tolerated the procedure well, was sent to
recovery room in stable condition.

At first, I was planning to just bill 52281 for the contracture dilation, but since the intent was to initially do the incision, would it be more appropriate to bill as 52276-52? I have read articles from the AUA’s Michael Ferragamo stating 52276 is appropriate for contracture incisions secondary to prostatectomies. Any help would be appreciated. Thanks in advance.

Medical Billing and Coding Forum

Attempted Consult

Hello!

My provider was called to do a in patient consult but was not able to finish due to the pt refusing medications and treatment. Can this still be billed and what code should be used? Please see notes below:

History of present illness: this is a 70 year Caucasian man, who was hospitalized 1st at Holmes regional medical center then at kindred hospital, for sepsis, right lower lobe pneumonia, metabolic encephalopathy, end-stage renal disease on peritoneal dialysis, chronic hypo-tension, symptomatic bradycardia, pacemaker implant, right BKA, left ft ulcers. The patient is refusing medications and treatment at this time. I have attempted to evaluate the patient but due to the patient’s explicit refusal the family agreed with not to go forward with the evaluation and I have abandoned to proceed. I understand there is as scheduled family meeting with palliative care for today this afternoon. If I could be of any help please do not hesitate to call me. Unfortunately, at this point I cannot do any further intervention.

Any feedback would be greatly appreciated!

Thanks

Medical Billing and Coding Forum

HELP! Attempted fracture reductions

Pt was seen in the office by our sports med doc. He attempted to reduce a metacarpal fx under nerve block, but was unsuccessful. He asked the pt to return in 1 week where he again, under nerve block tried to reduce the fx but was unsuccessful again. Sports med doc referred to in house ortho surgeon, for surgery consult. Pt went to surgery 2 weeks after initial attempted reduction. How would you code the first two visits with the sports med doc? E/M visit only, or fx manipulation code with -53 modifier?

Any help is appreciated!!

Medical Billing and Coding Forum

Attempted Endograft

Help! I am new to vascular coding. Any hints or helpful tips when coding vascular would be greatly appreciated. I am hopelessly lost figuring out the guides and glides and catheters and sheaths…give me back my basic CABG.

Procedures:
1. Left femoral and bilateral subclavian artery access
2. Placement of right femoral vein central lines.
3. Aortography, abdominal, thoracic, radiological supervision and interpretation
4. Left carotid to left subclavian bypass graft
5. Catheterization of the thoracic aorta with an attempt to place an endovascular graft.

Details of the Procedure:
In the operating room, the patient was placed in the supine position. She was mildly sedated and intubated by the anesthesiologist without complications. The operative field was prepped and draped in a usual sterile fashion. A right femoral vein was punctured and catheterized using standard Seldinger technique with the placement of the triple-lumen catheter. The right axillary and left subclavian artery were exposed through the transverse incisions parallel to both clavicles. The left carotid artery was exposed through the transverse incision just above the jugular notch. The right axillary artery was very large, soft, at least 12-14 mm in diameter, aneurysmal, without signs of atherosclerosis. The left subclavian artery was 5-6 mm in diameter,soft, without signs of atherosclerosis. Left common carotid artery was 7-8 mm in diameter, pulsatile, without significant atherosclerosis. First the"debranching" procedure of the left subclavian artery was performed by creating a bypass graft between the left common carotid artery and the left subclavian artery. A 10mm Hemashield graft was anastomosed end-to-side to the left common carotid artery and then it was tunneled through the subcutaneous subfascial tunnel and brought over the clavicle to the left subclavian area where it was anastomosed end-to-side to the left subclavian artery. The right axillary artery was punctured and catheterized using standard Seldinger technique and a #7-French sheath was placed with the insertion of the flexible guide wire and a pigtail catheter. In spite of multiple attempts of advancing the guidewire and the catheter into the aortic arch, we were unable to do so due to severe tortuosity of the innominate artery and aneurysmal changes at this level. We used multiple combinations of guidewires and catheters with different angles; however, they were not amenable to achieve advancement of the guidewire and/or the catheter into the aortic arch. Therefore we used the left subclavian artery for the arterial access. The artery was punctured and catheterized and the glidewire and the glide catheter were advanced into the aortic arch and the aortic arch angiography was performed following the propagation of the contrast into the descending aorta. The angiography revealed the fact that the patient had a Type B aortic dissection with the formation of the large descending thoracic aortic aneurysm impinging into the orifice of the left subclavian artery. In spite of multiple attempts to advance our guidewire and the catheter into the true lumen of the descending aorta, we were unable to do so due to the complex dissection fo the descending aorta, with the guidewire and catheter being trapped inside the dissected intima and in the false lumen of the aorta. An attempt was made to reach the true lumen of the descending aorta using a left carotid artery, where it was punctured and catheterized through the left carotid to left subclavian bypass graft with the retrograde advancement of the 6-French endovascular sheath into the lumen of the common carotid artery and the aortic arch. Again, however, multiple attempts to advance the guidewire into the true lumen of the descending aorta were not successful. A repeat thoracic aortography revealed the fact that the type B aortic dissection was almost completely occluding the true lumen of the aorta and the distal organ perfusion was maintained through the false lumen of the aortic dissection of the descending aorta. Considering these findings, we had to resort to the femoral approach in pursuing the goal of entering the true lumen of the thoracic aorta. Left femoral artery was exposed through transverse incision at the level of the left groin. the artery was moderately calcified, small, 6-7 mm in diameter, but pulsatile and suitable for catheterization. The artery was encircled with vessel loops. It was punctured and catheterized using standard, Seldinger technique and a #6-French endovascular sheath was placed. The guidewire and the glide catheter were advanced into the abdominal and subsequently distal thoracic aorta; however, again, in spite of multiple attempts and multiple combinations of different guidewires and angled catheters, we were unable to reach the true lumen of the descending thoracic aorta. It appeared that the flow to the distal organs was maintained through the false lumen of the descending aorta and the proximal abdominal aorta with the dissection extending into the abdominal aorta. An abdominal aortography was then performed that confirmed the diagnosis of extensive dissection that was propagating to the level of the abdominal aorta and aortic bifurcation. Considering these findings, we decided to abstain from placement of the endograft due to the high risk of creating malperfusion in this complex anatomy produced by the complex aortic dissection. Decision was made to limit the procedure to the debranching of the left subclavian artery and to defer the repair of the aorta to a later date after the patient undergoes further workup comprising CT Angiography and endovascular ultrasound. All catheters were removed under direct fluoroscopic guidance. All of the puncture sites in the arteries were closed with interrupted 6-0 Prolene sutures. Good pulses were reestablished throughout the area of exposed arteries. Thorough hemostasis was achieved using electrocautery and biological glue. There was significant amount of capillary bleeding from the area of the dissection of the right axillary and subclavian arteries due to presence of arteriovenous fistula and pressurized venous collateral branches. Bilateral Jackson-Pratt drains were placed in both axillary areas and also in the the left groin wounds. The incisions were irrigated with copious amount of saline containing antibiotics and closed in layers using standard technique. Sterile dressings were applied. The patient tolerated the procedure will and was transferred to recovery unit in stable condition.

Medical Billing and Coding Forum

Attempted Venous Decompression

I am having difficulty finding anything that can be billed in the scenario below. Please advise. Thank you in advance.

BSA: 1.89
Contrast: Low Osmolar Visipaque 320-1mL
Heparin given: 3000 units

Procedure: Attempted Venous Decompression

We attempted to gain access via patients right saphenofemoral vein and the left saphenofemoral vein. We were able to gain access, but it was difficult placing the sheaths, and then sheath access was lost on the right, and we were unable to place sheath access on the left. Subsequently, the procedure was terminated. We are going to get better assistance in ultrasound to attempt this procedure.

Medical Billing and Coding Forum | AAPC