Cardiology Coding Alert

Editors Note: If you have a cardiology case you would like to submit for consideration, please send it via fax, email or mail. Contact information is on page 18.

Case Description

The patient is a 69-year-old woman with defibrillation-related cardiac arrest. She has an extensive history of heart disease as well as prior cardiovascular surgery, and pacemaker placement in 1997. A cath, which was performed earlier, revealed normal coronaries. The cardiologist then tested the existing pacemaker and found it was not performing adequately. The skin was also starting to show erosion. Based on these findings, the cardiologist decides to place an implantable cardioverter defibrillator (ICD).

Procedure

Editors Note: We have condensed the following report from the cardiac catherization lab to describe the procedure relating to coding and reimbursement.

Because the patient had very little subcutaneous tissue or muscle tissue in the pectoral regions, the cardiologist elected to place the system in the abdomen.

Using Xylocaine 1% local anesthesia, a left delta pectoral incision was made and cephalic vein cutdown made. The Medtronic ICD lead Model 6945 (100 cm) was introduced. The lead was then secured to the underlying subcutaneous tissue and a loop made in the delta pectoral region. Another sleeve was anchored. The lead was then tunneled down to the abdomen where an incision was made and using blunt dissection, a pocket was fashioned and irrigated with antibiotic solution. A Medtronic Gem 7227CX ICD was connected and then placed in the abdominal pocket and anchored to the underlying subcutaneous tissues. The subcutaneous tissue and subcuticular tissue was closed. Prior to closure of the skin sutures, V-fib induction was performed. The first episode of ventricular fibrillation failed at 8 joules, but at 14 joules was successful in converting the rhythm to sinus.

A second episode of ventricular fibrillation was created and terminated promptly to sinus rhythm with a 14 joules shock.

Attention was geared to removal of the existing pacemaker system. The lead, with its significantly reduced impedance, was a problem. In addition, the atrial lead was nonfunctional, given the patients chronic atrial fibrillation. An incision was made over the area of the existing generator and this was carefully explanted. The leads were then placed in a cap and secured and placed back in the pocket. The existing pocket was irrigated using antibiotic solution and the subcutaneous tissue and subcuticular tissue.

There were no complications and the patient left the cardiovascular lab in satisfactory condition.

Coding Notebook

Lets look again at the report from the cardiac cath lab to determine the proper procedural codes.

First, the note describes the insertion of a complete cardioverter-defibrillator system with leads. The new lead was introduced and tested, then secured in place. A tunnel was formed to bring the lead [...]