AICD/RV Lead Fracture

em2177

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PREOPERATIVE DIAGNOSIS:
1. Right ventricular (RV) lead fracture.
2. Ischemic cardiomyopathy with class III heart failure.
3. Ejection fraction (EF) of 25%.
4. Automatic implantable cardioverter defibrillator (AICD), St. Jude Medical.

POSTOPERATIVE DIAGNOSIS:
1. Successful implantation of new right ventricular (RV) lead, St. Jude
Medical.
2. Successful pocket repositioning from sub-pectoralis to subcutaneous.
3. Capping of previous right ventricular (RV) lead.
4. Venogram of the right subclavian vein.

PROCEDURE(S) PERFORMED:
INDICATION: This patient is a very pleasant gentleman with history of ischemic
cardiomyopathy with EF of 25% with an old AICD. The patient's RV lead
fractured with noise. He is here for new RV lead placement.
The methods, risks, and benefits were explained to the patient, including the
risks of death, Ml, stroke, bleeding, and infection. The patient was prepped
in the usual sterile fashion. Xylocaine 1% was applied to the right chest
wall, thus causing local sedation. A combination of blunt and sharp dissection
created and opened up the pocket. Thereafter the right venogram of the
subclavian vein was made. Using a 19-gauge needle the subclavian vein was
accessed. Then we were able to place a Glidewire into the right subclavian
vein. We dilated up the right subclavian from a 7-French dilator to an
8-French dilator. We placed the 8-French sheath into the right subclavian vein.
A combination of curved and straight stylets was used to place the RV lead in
the right septal area, right next to the previous RV lead, positioned almost
identically, but there was no touching of the previous RV lead. We found
appropriate thresholds and impedances at that point in the right outflow tract
area. Therefore, we sutured the lead to the chest wall.
We flushed the pocket with antibiotic solution. We went ahead and opened up
the previous AICD pocket, which is a sub-pectoralis pocket. After intensive
dissection of the pocket we were able to extract the device. We went ahead and
removed the previous RV lead and placed 3 of the RV leads. We placed the
device in the subcutaneous tissue area, since we felt this was a better
position, more superficial than sub-pectoralis. We flushed the pocket with
antibiotic solution and closed the device with running 2-0 and 4-0 Monocryl in
4-layer fashion, first in a continuous fashion with 2-0, then with a continuous
2-0 Monocryl, and then we used 1 layer of 4-0 Monocryl. We placed Dermabond
superficially and closed the pocket with Steri-Strips. Prior to placing
Steri-Strips we flushed the pocket superficially with peroxide.
The patient tolerated the procedure uneventfully. We did not do DFT testing,
since the patient has severe cardiomyopathy and his lead positioning was
exactly the same position as DFTs before which were appropriate. We put it at
high energy. The DFT before was 22 joules. We therefore placed the maximum
shock at 40 joules of energy.

The patient tolerated the procedure uneventfully. There were no complications.
 
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Recommended Codes for Case

Hi Elizabeth; it would be best to clarify the contradiction in the report with the physician. The 3rd item under the "postoperative diagnosis" section says "capping of previous right ventricular (RV) lead." This suggest that the damaged lead was left in place. However, in the "procedures performed" section the doctor says "We went ahead and removed the previous RV lead and placed 3 of the RV leads." The comment about placing 3 RV leads really makes no sense; I anticipate it was a transcription error of some sort.

If you can confirm that the old RV lead was capped and left in place, the appropriate coding would be as follows:


33216 - Insertion of a single transvenous electrode, permanent pacemaker or cardioverter-defibrillator
33223 - Revision of skin pocket for cardioverter-defibrillator

If you confirm that he/she actually removed the old RV lead, you would add the following code to the mix:

33244 - Removal of single or dual chamber pacing cardioverter-defibrillator electrode(s); by transvenous extraction

The venogram mentioned in the report is not separately billable. There are many sources establishing that diagnostic venography is not reportable when done for road-mapping or to guide another procedure. The following Q&A from the AMA is representative:

“Question: During the insertion of a dual-chamber implantable cardioverter-defibrillator, the physician indicated a left subclavian venogram was obtained to facilitate entry. Is it appropriate to report code 75820, Venography, extremity, unilateral, radiological supervision and interpretation, separately in addition to codes 33249, Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter- defibrillator and insertion of pulse generator and code 71090, Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation?
Answer: No. The service described is not a diagnostic venogram, but is rather used for guidance of the leads "obtained to facilitate entry." Therefore, it would not be appropriate to separately report code 75820.”
CPT® Assistant Code Connect, May 2008

I hope this helps and I wish you the best of luck.

Jim Collins, CPC, CCC
President, CardiologyCoder.Com

YOUR ORIGINAL QUESTION FOLLOWS:


Need assistance in coding this report. Thank You!

PREOPERATIVE DIAGNOSIS:
1. Right ventricular (RV) lead fracture.
2. Ischemic cardiomyopathy with class III heart failure.
3. Ejection fraction (EF) of 25%.
4. Automatic implantable cardioverter defibrillator (AICD), St. Jude Medical.

POSTOPERATIVE DIAGNOSIS:
1. Successful implantation of new right ventricular (RV) lead, St. Jude
Medical.
2. Successful pocket repositioning from sub-pectoralis to subcutaneous.
3. Capping of previous right ventricular (RV) lead.
4. Venogram of the right subclavian vein.

PROCEDURE(S) PERFORMED:
INDICATION: This patient is a very pleasant gentleman with history of ischemic
cardiomyopathy with EF of 25% with an old AICD. The patient's RV lead
fractured with noise. He is here for new RV lead placement.
The methods, risks, and benefits were explained to the patient, including the
risks of death, Ml, stroke, bleeding, and infection. The patient was prepped
in the usual sterile fashion. Xylocaine 1% was applied to the right chest
wall, thus causing local sedation. A combination of blunt and sharp dissection
created and opened up the pocket. Thereafter the right venogram of the
subclavian vein was made. Using a 19-gauge needle the subclavian vein was
accessed. Then we were able to place a Glidewire into the right subclavian
vein. We dilated up the right subclavian from a 7-French dilator to an
8-French dilator. We placed the 8-French sheath into the right subclavian vein.
A combination of curved and straight stylets was used to place the RV lead in
the right septal area, right next to the previous RV lead, positioned almost
identically, but there was no touching of the previous RV lead. We found
appropriate thresholds and impedances at that point in the right outflow tract
area. Therefore, we sutured the lead to the chest wall.
We flushed the pocket with antibiotic solution. We went ahead and opened up
the previous AICD pocket, which is a sub-pectoralis pocket. After intensive
dissection of the pocket we were able to extract the device. We went ahead and
removed the previous RV lead and placed 3 of the RV leads. We placed the
device in the subcutaneous tissue area, since we felt this was a better
position, more superficial than sub-pectoralis. We flushed the pocket with
antibiotic solution and closed the device with running 2-0 and 4-0 Monocryl in
4-layer fashion, first in a continuous fashion with 2-0, then with a continuous
2-0 Monocryl, and then we used 1 layer of 4-0 Monocryl. We placed Dermabond
superficially and closed the pocket with Steri-Strips. Prior to placing
Steri-Strips we flushed the pocket superficially with peroxide.
The patient tolerated the procedure uneventfully. We did not do DFT testing,
since the patient has severe cardiomyopathy and his lead positioning was
exactly the same position as DFTs before which were appropriate. We put it at
high energy. The DFT before was 22 joules. We therefore placed the maximum
shock at 40 joules of energy.

The patient tolerated the procedure uneventfully. There were no complications.
__________________
Elizabeth M. CPC
 
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