Can anyone advice whether we can code temporary pacemaker and permanent pacemaker on same day? The NCCI edit shows with 59 modifier is applicable.
can anyone help me to code this MR?
Preoperative Diagnosis: Syncope; Symptomatic Bradycardia; 3rd degree AV block; Conduction system disease with Bi-Fascicular Block.
Postoperative Diagnosis: Same as pre-op.
Procedures performed:
1) Left subclavian venogram.
2) Dual chamber permanent pacemaker implantation (Biotronik).
3) Analysis of atrial and ventricular leads.
4) Moderate sedation.
5) Temporary Transvenous Pacemaker Placement (through right femoral vein).
6) Ultrasound guided access of the right femoral vein.
CONSENT: Full benefits, risks, and alternatives to the procedure were explained to the patient. Informed consent was obtained from the patient.
PROCEDURE IN DETAIL: The patient was brought to the operating room in a fasting state. Left side of the chest was prepped in the usual sterile fashion. A time out was performed, and then moderate sedation was administered per protocol. Prior to making the incision prophylactic
antibiotics (with IV Ancef) were administered per protocol. Using real-time u/s guidance and lidocaine for local anesthesia the right femoral vein was accessed (single stick, single wall) and a 6Fr venous sheath was placed using modified seldinger technique. A balloon-tipped Temporary TV pacemaker was inserted into the RV. Lidocaine 1% was used as the local anesthetic to the left chest. A left subclavian/axillary venogram was performed and showed a patent subclavian vein. Subsequently, a blade was used to make a horizontal incision at the left chest (located slightly lateral to the mid-axillary line, approximately two inches in length and two finger breadths below the clavicle). A pocket was created using blunt dissection down to the pectoralis fascia; bleeding points were take care of using electrocautery. A percutaneous needle was introduced into the left subclavian vein under fluoroscopic guidance. Through the needle, after adequate venous flow was noted, the guidewire was passed and positioned in inferior vena cava under fluoroscopic guidance. Once the guidewire was in position, an 0-Ethibond suture was placed in a figure of 8 pattern. The 8 French sheath was inserted over the 0.035" wire; the introducer was removed and sheath flushed. A ventricular lead of BIOTRONIK Corporation was then introduced and advanced under fluoroscopic guidance with the help of a straight stylet into the right atrium. The straight stylet was then curved and re-inserted into the RV lead and used to position the lead at the apex. The lead was then actively fixated under fluoroscopic guidance. A good injury current was noted. The following parameters were obtained, which were within acceptable range: The R-wave amplitude was 7.6 millivolts The Lead impedance was 760 ohms Ventricular capturing threshold was 0.6 volts at 0.40ms. There was no diaphragmatic stimulation at 10 volts. Once the ventricular lead was adequately positioned, the guidewire was reinserted into the 8F sheath under fluoroscopic guidance, and sheath was split and removed over the wire. Then a 6 French introducer along with a sheath was inserted over the guidewire into the left subclavian vein. The atrial lead of BIOTRONIK Corporation was then advanced into the atrium with a straight wire. The straight wire was replaced with a Jshaped stylette and the lead was then positioned in the right atrial appendage; the lead was then actively fixated in place under fluoroscopic guidance. A good injury current was noted. The J-stylette was removed under fluoroscopic guidance and lead remained in place; a straight stylette was then inserted to the mid-portion of the lead. The following parameters were obtained, which were within acceptable range. The P-wave amplitude was 4.2 millivolts The Lead impedance was 702 ohms Atrial capturing threshold was 1.2 volts at 0.40ms. There was no diaphragmatic stimulation at 10 volts. Appropriate slack was provided to both leads and the sheath was peeled back and removed. Hemostasis was secured by closing the figure of 8 Ethibond suture. The leads were re-imaged and slack readjusted as needed. At this stage, the pocket was reinspected and small areas of bleeding were treated with electrocautery and the hemostasis was notably satisfactory. Both atrioventricular leads were secured to the chest wall, each with two 0-silk sutures. The pocket was then irrigated with triple antibiotic solution numerous times. The pocket was noted to be clean and dry on visual inspection. Both leads were then connected to the pulse generator of BIOTRONIK Corporation in hermetic fashion; "tug-test" was performed and both leads were secured in place within the generator. The pulse generator was placed in the preformed pocket and secured with 0-ethibond suture. Before closing the pacer pocket, Floseal was administered for additional hemostasis. The pocket was then closed with a single running 2-0 Vicryl layer, a double-running 3-0 Vicryl layer. Finally, DermaBond was applied to the pacer wound. The temporary pacemaker was removed under fluoroscopic guidance without issue. The patient tolerated the procedure well.