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Old 06-07-2013, 10:18 AM
lcouto lcouto is offline
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Default Loop recorder removal/pacer insert

Hi. Patient had a loop recorder implanted in March.. 3 weeks later my doctor removed the loop recorder and inserted a Dual Chamber Pacemaker.. When we billed this we billed a 33284 for the removal of the loop recorder and a 33208 for the pacer insert. Medicare is denying stating Payment is included in allowance for other procedure. Was this billed correctly or should there be a modifier used? Please help !!! I attached the report

Pre-procedure Diagnoses
1. Tachy-brady syndrome
2. Paroxysmal atrial fibrillation

Post-procedure Diagnoses
1. Tachycardia-bradycardia
2. Paroxysmal a-fib
BRIEF OPERATIVE NOTE


Date of Surgery:
4/12/2013


Pre-operative Diagnosis:
Tachycardia- Bradycardia Syndrome
Paroxysmal Atrial fibrillation


Post-operative Diagnosis:
Same as above


Procedure Performed :
Implantation of Permanent Pacemaker
Removal of Reveal XT loop Recorder

Specimens Removed:
Medtronic Reveal XT RAB 483394H


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.


ACCESS and POCKET FORMATION:
Lidocaine was used to infiltrate the skin and subcutaneous tissue overlying the left pectoralis muscle. The patient was placed in Trendelenburg position. Percutaneous access was obtained in the subclavian vein utilizing the modified Seldinger technique. An .035 wire was advanced into the right atrium under fluoroscopic guidance. Sharp incision was made in the skin. Utilizing a combination of sharp and blunt dissection, a pocket was formed in the prepectoral fascia. I was able to dissect along the prepectoral fascia and removed the Reveal XT loop recorder through the incision for the pacemaker pocket.

VENTRICULAR LEAD:
Over the .035 wire, an 8 French peel-away sheath was advanced. The dilator was removed, and a second .035 wire wa
s placed through the sheath. The sheath was removed and then reintroduced over one of the .035 wires. The wire and dilator were exchanged then for the ventricular pacing lead. The lead was an passive fixation lead (Medtronic 4092-58 with serial number LEP521453V) 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 11.3 mV, impedance 564 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 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 5076-52 with serial number PJN3002013.) 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 3.8 mV, impedance 866 ohms, threshold was 1.0 volts, current 1.6 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 ADAPTA ADDR01 with serial number NWB233430H) The leads and pulse generator were incorporated in the pocket. The pocket was copiously irrigated. The subcutaneous fascia was closed with interrupted Vicryl suture. The skin layer was closed with a subcuticular Vicryl stitch. Final fluoroscopy demonstrated adequate slack in the leads. The wound was dressed in a sterile fashion.
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Old 06-09-2013, 11:00 AM
TWinsor TWinsor is offline
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looks correct to me. There is not a CCI edit. I would appeal with notes.

HTH
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  #3  
Old 06-10-2013, 04:23 AM
theresa.dix@ethc.com theresa.dix@ethc.com is offline
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Quote:
Originally Posted by lcouto View Post
Hi. Patient had a loop recorder implanted in March.. 3 weeks later my doctor removed the loop recorder and inserted a Dual Chamber Pacemaker.. When we billed this we billed a 33284 for the removal of the loop recorder and a 33208 for the pacer insert. Medicare is denying stating Payment is included in allowance for other procedure. Was this billed correctly or should there be a modifier used? Please help !!! I attached the report

Pre-procedure Diagnoses
1. Tachy-brady syndrome
2. Paroxysmal atrial fibrillation

Post-procedure Diagnoses
1. Tachycardia-bradycardia
2. Paroxysmal a-fib
BRIEF OPERATIVE NOTE


Date of Surgery:
4/12/2013


Pre-operative Diagnosis:
Tachycardia- Bradycardia Syndrome
Paroxysmal Atrial fibrillation


Post-operative Diagnosis:
Same as above


Procedure Performed :
Implantation of Permanent Pacemaker
Removal of Reveal XT loop Recorder

Specimens Removed:
Medtronic Reveal XT RAB 483394H


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.


ACCESS and POCKET FORMATION:
Lidocaine was used to infiltrate the skin and subcutaneous tissue overlying the left pectoralis muscle. The patient was placed in Trendelenburg position. Percutaneous access was obtained in the subclavian vein utilizing the modified Seldinger technique. An .035 wire was advanced into the right atrium under fluoroscopic guidance. Sharp incision was made in the skin. Utilizing a combination of sharp and blunt dissection, a pocket was formed in the prepectoral fascia. I was able to dissect along the prepectoral fascia and removed the Reveal XT loop recorder through the incision for the pacemaker pocket.

VENTRICULAR LEAD:
Over the .035 wire, an 8 French peel-away sheath was advanced. The dilator was removed, and a second .035 wire wa
s placed through the sheath. The sheath was removed and then reintroduced over one of the .035 wires. The wire and dilator were exchanged then for the ventricular pacing lead. The lead was an passive fixation lead (Medtronic 4092-58 with serial number LEP521453V) 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 11.3 mV, impedance 564 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 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 5076-52 with serial number PJN3002013.) 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 3.8 mV, impedance 866 ohms, threshold was 1.0 volts, current 1.6 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 ADAPTA ADDR01 with serial number NWB233430H) The leads and pulse generator were incorporated in the pocket. The pocket was copiously irrigated. The subcutaneous fascia was closed with interrupted Vicryl suture. The skin layer was closed with a subcuticular Vicryl stitch. Final fluoroscopy demonstrated adequate slack in the leads. The wound was dressed in a sterile fashion.

Both 33282 and 33284 have 90 day global period. So you will need to add a modifier. Now which one ?
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