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Thanks!
We had billed this service using an unlisted procedure code 33999,(in addition to the pacemaker code 33206) per Medtronic as there isn’t a procedure code specific for this service and were denied by Medicare for the 33999 as not separately payable. The claim was appealed with records. Still denied.
Thank you in advance for any information.
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.
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
I have found the below documentation from the 2010 ICD-9 Coding Clinic that states if a pacemaker is placed to treat the sick sinus syndrome, that only the pacemaker code should be used. I am not able to find any documentation that shows this has changed. Would this only occur during the interrogation? Would you be able to bill both codes out at a regular follow-up visit?
Would a complete heart block fall into the same situation? I am not able to find any official documentation to confirm if the complete heart block and pacemaker codes can be used together.
Not billing the complete heart block would affect the patient’s risk score just as with the sick sinus syndrome.
Any and all help is greatly appreciated!
Thank you – Missy
ICD-9-CM Coding Clinic, Third Quarter 2010 Pages: 9-10 Effective with discharges: October 1, 2010
Question:
Coding Clinic, Fifth Issue 1993, page 12, advised that when sick sinus syndrome (SSS) is controlled by a pacemaker, no code assignment is required if no attention or treatment is provided to the condition or the device. However, we are seeing records where the patient is admitted for an unrelated condition, but during the stay the physician does an interrogation of the pacemaker. Is it appropriate to assign a code for sick sinus syndrome, as a chronic condition, when a patient has a previously placed pacemaker and it is interrogated during the hospitalization?
Answer:
Assign code V53.31, Fitting and adjustment of other device, Cardiac device, cardiac pacemaker, as an additional code assignment. A code is not assigned for sick sinus syndrome when it is being controlled by the pacemaker and no problems are detected during the check. Interrogation is a routine check, which is done via computer to assess pacemaker function. The pacemaker is routinely evaluated to ensure the device is programmed accurately as well as to assess battery and lead function. Pacemaker settings may be reprogrammed, if required. Interrogation of the device can be done in the inpatient setting or in the office setting.
Code 89.45, Artificial pacemaker rate check, may be assigned for the procedure.
The case is as follows:
PREPROCEDURE DIAGNOSIS: Acute inferior ST segment elevation myocardial
infarction complicated by complete heart block and hypotension.
POSTPROCEDURE DIAGNOSIS: Coronary artery disease.
PROCEDURE PERFORMED:
1. Emergent coronary angiography.
2. Temporary right ventricular pacemaker insertion.
3. Emergent percutaneous transluminal coronary stenting of the mid right
coronary artery, performed in the setting of acutely occluded coronary
vessel with acute myocardial infarction (3 drug-eluting stents placed in
one coronary vessel).
INDICATIONS FOR PROCEDURE: A male with Parkinson’s
disease, presenting with syncope, but without chest pain, but was found on
ECG to have acute inferior ST segment elevation myocardial infarction
associated with a severe complete heart block with a heart rate of 25
beats per minute and the systolic blood pressure of 80-100 mmHg.
The patient was brought emergently from the paramedics into the cardiac
catheterization lab with ongoing complete heart block and hypotension.
The right groin area was prepped and draped in the usual sterile fashion
and anesthetized locally with 1 percent Xylocaine. The right femoral
artery and vein were punctured with modified Seldinger technique and
6-French sheaths were introduced into both vessels. A 6-French temporary
pacemaker electrode was placed in the right ventricular apex and temporary
pacing was performed, which resulted in hemodynamic improvement. We then
used a 6-French JR4 guide catheter to cannulate the right coronary artery.
The left coronary artery was cannulated with a 5-French JL4 diagnostic
catheter.
I did not attach the complete case, because I didn’t think the rest was necessary for my question. The temporary pacemaker was removed during this same procedure. Would I use 33210 for the temporary pacemaker as well as 92941?
Pre-operative Diagnosis:
( ) Tachycardia- Bradycardia Syndrome- medical control of tachycardia is associated with symptomatic episodes of bradycardia
( ) Documented nonreversible symptomatic bradycardia due to sinus node dysfunction
( X) Documented nonreversible symptomatic bradycardia due to second-degree and/or third-degree atrioventricular block.
*
Post-operative Diagnosis:
Same as above
*
Procedure Performed :
Implantation of Permanent Pacemaker
Venogram
Repositioning of the RUE mediport
*
Surgeon:
*
Assistant & Staff:
*
Anesthesia:
Moderate Conscious Sedation
*
Total IV Fluids & Blood loss;
Minimal blood loss
*
Drains:
None
*
Specimens Removed:
None
*
Implants and Procedure Description:
After informed consent was obtained, the patient was transported in a nonsedated condition to the cardiac catheterization suite. The patient was given moderate conscious sedation. The patient was prepped and draped in a sterile fashion and a "timeout" was taken. During this procedure, I administered moderate conscious sedation using midazolam and fentanyl (totals for each documented in chart.) I was assisted in monitoring the patients level of consciousness, blood pressure, heart rate, arterial saturation, and respiratory rate by an independent, critical care nurse as documented in the chart. Pre-and post procedure assessment and monitoring was performed. My documented intraservice time (continuous face to face time after administration of sedation until I exited the room) was 80 min.
*
Venogram
10 cc of contrast was administered via right brachial IV. Patency of the right subclvian vein was confirmed.
*
*
ACCESS and POCKET FORMATION:
Lidocaine was used to infiltrate the skin and subcutaneous tissue overlying the right pectoralis muscle. Incision was made beneath the left upper chest mediport. I then carefully dissected the port free and moved it medially and rescured it to the chest wall. The pocket was extended inferiorly and laterally from the port.
*
The patient was placed in Trendelenburg position. Using ultrasound guidance, percutaneous access was obtained in the subclavian vein utilizing the modified Seldinger technique. An .035 wire was advanced into the superior vena cava under fluoroscopic guidance. Percutaneous access was again performed in the left subclavian with placement of a second 0.035 wire. Sharp incision was made in the skin. Utilizing a combination of sharp and blunt dissection, a pocket was formed in the prepectoral fascia.
**
VENTRICULAR LEAD:
Over the .035 wires, 8 French peel-away sheaths were advanced. The dilators were removed. The wire and dilator were exchanged then for the ventricular pacing lead. The lead was an active fixation lead (Medtronic) Utilizing curved and straight stylettes, the lead was positioned and secured in the right ventricular apex. It was tested and found to have R waves of 9.8 mV, impedance 638 ohms, threshold was 0.7 volts, current 1.7 milliamps. Adequate slack was placed in the lead under fluoroscopic guidance. The lead was tested with output of 10 V and did not stimulate the diaphragm.
*
ATRIAL LEAD:
Attention was then turned to the atrial lead. Over the second .035 wire a second dilator and sheath were placed. The wire and dilator were exchanged then for the atrial pacing lead. The lead was an active fixation lead (Medtronic) Utilizing curved and straight stylettes, the lead was positioned and secured in the right atrial appendage. It was tested and found to have P waves of 1.8 mV, impedance 483 ohms, threshold was 0.6 volts, current 1.3 milliamps. Adequate slack was placed in the lead under fluoroscopic guidance. The lead was tested with an output of 10 V and did not stimulate the diaphragm.
*
CLOSURE:
The leads were then secured to the pectoralis muscle with non-resorbable suture. I then attached the pulse generator (Medtronic ) The leads and pulse generator were incorporated in the pocket. The pocket was copiously irrigated with antibiotic solution. The subcutaneous fascia was closed with interrupted 3-0 Vicryl suture. The skin layer was closed with a running subcuticular 4-0 Vicryl suture and Surgiseal adhesive. Final fluoroscopy demonstrated adequate slack in the leads. The wound was dressed in a sterile fashion.
*
*
*