Broomfield, CO
Best answers
I am having trouble with this one. I have studied the note and I don't see 3 leads which is what you need for BiV PPM insertion. So, I'm struggling with the coding. One option I believe is:
33207 – insertion of new perm pacemaker with transvenous electrode(s); ventricular
33216 – insertion of single transvenous electrode
33225 – insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator.
Can anyone with more pacemaker coding experience read the note and give me your thoughts? Thanks you in advance!
The risks, benefits, and alternatives of the procedure were all discussed with the patient. The consent was signed and placed in the chart. The patient was taken to the cardiac catheterization laboratory in the fasting state. A time-out was performed. Thirty minutes prior to and during the procedure, prophylactic antibiotics (Ancef) were administered and a venogram from the left arm IV was performed. This identified a widely patent axillary/subclavian system to the level of the right heart. The patient was prepped and draped in sterile fashion for permanent pacemaker insertion. 30 mL of a combination of 1% Lidocaine and 0.5% of Bupivicaine was infiltrated into the subcutaneous region below the left clavicle to provide local anesthesia.
Conscious sedation was utilized throughout the procedure. A horizontal incision was made in the left infraclavicular region and sharp and blunt dissection were used to fashion the pacemaker pocket. Electrocautery was used for hemostasis. An antibiotic-soaked sponge was then placed in the pocket. Using an 18 gauge Cook needle and the modified Seldinger technique, the left axillary vein was accessed at the level of the 1st rib. A 0.035 guidewire was then passed through the Cook needle and into the right heart under fluoroscopic guidance. A 2nd J-wire was placed using the same procedure, again under fluoroscopic guidance into the right heart.
Using the 1st wire, a 6 French safe peel away sheath was then placed in the axillary vein. This allowed passage of the right ventricular lead into the right ventricular apex where the lead was screwed into place. The sheath was torn away and the lead tested. This demonstrated adequate capture and sensing thresholds. The lead was then secured to the pacemaker pocket floor using 0 Ethibond.
Using the remaining J-wire, a 9 French safe sheath was placed in the axillary vein over the J-wire and the J-wire removed. A Whorley catheter was introduced and engaged with the coronary sinus. Once the CS was engaged, a venogram was done. A balloon-tip pulmonary wedge catheter was used to perform coronary sinus angiography, which identified a posterolateral branch arising from the CS. The CS bifurcated early into a second branch that paralleled the main CS in the AV groove.
The balloon-tip pulmonary wedge catheter was then removed and an angled Glidewire was advanced into the posterolateral branch. An inner catheter was then advanced over the Glidewire for additional support and the Glidewire was then exchanged for a 0.014 guidewire. At this point, the left ventricular lead was inserted and advanced to the level of the posterolateral branch but would not enter the ostium of the vessel in question. After several attempts, the Glidewire and LV lead were removed. A Runthrough wire was then inserted over the inner catheter and into the low posterolateral vessel. The left ventricular lead was then advanced over the wire. Several attempts were made to advance the LV lead into the posterolateral vessel; however, doing so caused the wire and LV lead to retract completely from the ostium of the vessel. The wire was then re-advanced and successfully inserted into the high posterolateral vessel. The LV lead was then subsequently advanced over the wire into the high posterolateral branch. The sheath was then torn away, the inner catheter removed and the lead tested. This demonstrated adequate capture and sensing thresholds, albeit with diphragam stem at close to the pacing thresholds. The lead was then secured to the pacemaker pocket floor using 0 Ethibond and the wire was subsequently removed.
At this point, the antibiotic soaked sponge was removed from the pocket. The pocket was inspected and all bleeders were cauterized. The pocket was then irrigated with copious amounts of antibiotic-containing solution.
The device was then brought to the field and affixed to the header according to manufacturer guidelines. The serial numbers for both the RV and coronary sinus lead leads were checked and placed into the middle and lower pole lead housings and the set screws were firmly screwed into place. The atrial port was plugged with an atrial port plug. This documented ventricular pacing at the backup rate of the pacemaker. The device and the redundant portions of both leads were then placed in the pocket. The device was sutured into place with 0 Silk. The pocket was then closed in 3 layers, initially with 2 layers of interrupted suture using 2 0 and 3 0 Vicryl, and finally Stratafix for the skin. A dry sterile dressing was applied.

The temporary pacer wire was removed under fluoroscopy and femoral venous sheath was removed and pressure held.
1. Device
Model: Edora 8 DR-T
Serial Number: 70202506
Lower Rate: 60 BPM
Upper Rate: 130 BPM
2. Right Ventricular lead
Device: Solia S 60 Serial Number: 8000430915
R Wave 3.4 mV paced from temp pacer Threshold 0.7 V at 0.4 millisec
3. Left Ventricular lead
Device: Solia S 60 Serial Number: 8000511515
R Wave 4.3-7.3 mV paced Threshold 1.3V at 1 millisec

Jim Pawloski

True Blue
Ann Arbor
Best answers
You have 32207 and 33225 for you pacemaker insertion You don't have an atrial wire and the report states "The atrial port was plugged with an atrial plug. So, you do have a biventricular pacemaker as one lead is working the right ventricle and the CS wire is working the left ventricle.
Jim Pawloski, CIRCC