bevann0402@bellsouth.net
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When I think I have the code narrowed down, I start second guessing. Any help will be greatly appreciated. and Merry Christmas, Happy Holidays, Seasons Greetings To All!!
Procedure Performed:
1. Fluroscopy for isolation of the right subclavian vein.
2. right subclavian venography x 1
3. RA angiography x 1
4. RV angiograhy x 2
5. RV ICD lead revision
6. RA lead revision
7. Pacemaker pocket revision
Complications: none immediately
Intended procedure was upgrade of ICD to a BiV ICD due to a wide QRS, LVEF less than 30%, and continued congestive heart failure as an outpatient and inpatient.
The details of upgrade from an ICD to a BiV ICD were explained in great detail including risk factors.
The pacemaker pocket was examined. Fluoroscopy was used to isolate the left subclavian vein. Left subclavian venography was performed x 1, showing a small to medium left subclavian vein with two leads going through it at mid clavicle. It appears that the original pacemaker site was done from a cephalic vein cutdown. Next, the pacemaker site was numbed up utilizing a lidocaine solution. Next a scalpel was used to make a dissection across the mid level of the pacemaker device. Caution was used not to cut any leads or not to cut down to the pacemaker device itselt. Cautery and Bovie was used to get down to the pacemaker can site. next, scissors were used to continue to open up the callus and to expose the pacemaker device.
Extensive revision of the RV ICD lead and the RA lead was required. We went on to a laser cautery and Bovie to perform this. Since it was orginally a cephalic cutdown, we were trying to go mid clavicle. There was an extensive dissection of both the RV lCD lead and the RA lead. Also, the pacemaker pocket itself due to the callus being more lateral was actually revised to make it more medial. It was a long incision at the beginning of the case due to perform this.
next, we took down the ____ coronary sinus sheath and we did end up performing an RV angiography x 2 to try to identify the coronary sinus, as well as an RA angiography x 1. The coronary sinus was identified. it has a small opening. It has an inferior-posterior take-off. Multiple attempts were used to try to cannulate the coronary sinus. We did attempt an IMA inside the ___ sheath. We did attempt an RCA diagnostic coronary diagnostic catheter. We attempted a 2 Wholey wire technique where a Wholey wire was placed into the outflow tract, and then we attempted to cannulate the coronary sinus this way. We used a total of over 2 hours of lab time and 40 minutes of fluoro. There was a total of 40 cc of IV contrast used for multiple injections here. Ultimately, due to increasing timing, and the patient becoming (un)comfortable on the table, the decision was made to halt the case. Vital signs were stable at this decision. Patient was without compliants.
Next, we decided to halt case and thus the pacemaker pocket was thoroghly flushed utlizing antibiotic solution. bleeding was controlled. we did place an antibiotic pocket around the old ICD device to help prevent secondary infections.
The ICD which was previously used was placed into the new revised pacemaker pocket with the antibiotic sleeve on top. and we made sure the leads were behind the can by fluoroscopy. the deep structures were closed utilizing interrupted absorbable sutures. the skin layer was closed with interrupted staples. pressure dressing and ice pack applied, patient will remain overnight for monitoring. will require 24 hour anitbiotics.
I keep going between cpt codes 33224 and 33226. Am I near right or do I need other codes?
Thanks in advance for your help!!
Beverly Abernathy, CPC, CIMC
Procedure Performed:
1. Fluroscopy for isolation of the right subclavian vein.
2. right subclavian venography x 1
3. RA angiography x 1
4. RV angiograhy x 2
5. RV ICD lead revision
6. RA lead revision
7. Pacemaker pocket revision
Complications: none immediately
Intended procedure was upgrade of ICD to a BiV ICD due to a wide QRS, LVEF less than 30%, and continued congestive heart failure as an outpatient and inpatient.
The details of upgrade from an ICD to a BiV ICD were explained in great detail including risk factors.
The pacemaker pocket was examined. Fluoroscopy was used to isolate the left subclavian vein. Left subclavian venography was performed x 1, showing a small to medium left subclavian vein with two leads going through it at mid clavicle. It appears that the original pacemaker site was done from a cephalic vein cutdown. Next, the pacemaker site was numbed up utilizing a lidocaine solution. Next a scalpel was used to make a dissection across the mid level of the pacemaker device. Caution was used not to cut any leads or not to cut down to the pacemaker device itselt. Cautery and Bovie was used to get down to the pacemaker can site. next, scissors were used to continue to open up the callus and to expose the pacemaker device.
Extensive revision of the RV ICD lead and the RA lead was required. We went on to a laser cautery and Bovie to perform this. Since it was orginally a cephalic cutdown, we were trying to go mid clavicle. There was an extensive dissection of both the RV lCD lead and the RA lead. Also, the pacemaker pocket itself due to the callus being more lateral was actually revised to make it more medial. It was a long incision at the beginning of the case due to perform this.
next, we took down the ____ coronary sinus sheath and we did end up performing an RV angiography x 2 to try to identify the coronary sinus, as well as an RA angiography x 1. The coronary sinus was identified. it has a small opening. It has an inferior-posterior take-off. Multiple attempts were used to try to cannulate the coronary sinus. We did attempt an IMA inside the ___ sheath. We did attempt an RCA diagnostic coronary diagnostic catheter. We attempted a 2 Wholey wire technique where a Wholey wire was placed into the outflow tract, and then we attempted to cannulate the coronary sinus this way. We used a total of over 2 hours of lab time and 40 minutes of fluoro. There was a total of 40 cc of IV contrast used for multiple injections here. Ultimately, due to increasing timing, and the patient becoming (un)comfortable on the table, the decision was made to halt the case. Vital signs were stable at this decision. Patient was without compliants.
Next, we decided to halt case and thus the pacemaker pocket was thoroghly flushed utlizing antibiotic solution. bleeding was controlled. we did place an antibiotic pocket around the old ICD device to help prevent secondary infections.
The ICD which was previously used was placed into the new revised pacemaker pocket with the antibiotic sleeve on top. and we made sure the leads were behind the can by fluoroscopy. the deep structures were closed utilizing interrupted absorbable sutures. the skin layer was closed with interrupted staples. pressure dressing and ice pack applied, patient will remain overnight for monitoring. will require 24 hour anitbiotics.
I keep going between cpt codes 33224 and 33226. Am I near right or do I need other codes?
Thanks in advance for your help!!
Beverly Abernathy, CPC, CIMC