Case # 20 ? answers & rationale


Best answers
Can anyone offer an explanation or rationale for Infected Pacemaker Case# 20 answer(s)?
CPT 33208, 33234, 33233
Modifier none or 51
ICD-9-CM 996.61


See which answers this post.

Case #20 Winner, Answer Key, & Rationale
See below for answers and rationale.

CPT: 33208, 33234, 33233
CPT Modifiers: none or 51
ICD-9: 996.61

In this case the provider removes a single lead system and replaces with a dual lead system. This procedure is not coded as an upgrade because the existing ventricular lead is removed. To be coded as an upgrade, it requires reopening the pacemaker pocket, placing a second lead into the atrium, verifying the pacing parameters on the existing ventricular lead and connecting both the new and the old lead to a new dual chamber pulse generator.

CPT: 33208, 33234-51, 33233-51 or 33208, 33234, 33233

Steps to look up: Pacemaker, Heart/Insertion/33206-33208; Pacemaker, Heart/Removal/Transvenous Electrodes; Pacemaker 33234-33235; Pacemaker, Heart/Removal/Pulse Generator Only 33233. Pacemaker, Heart/Relocation Pocket/Chest 33222, 33223 ? CPT notes indicate to code the relocation of the pocket; however, code 33208 includes creation of a pocket, so it is not reported.

ICD-9-CM: 996.61
Steps to look up: Complications/pacemaker (cardiac)/infection or inflammation
Last edited by; Yesterday at 02:30 PM.

Hint: This patient is presenting symptoms of an infected pacemaker with need for AV nodal pacing backup. Since there are complications with this procedure, you?ll need your CCI edits and lay terms to code this case.

Case #20

Preoperative diagnosis: Infected pacemaker

Postoperative diagnosis: Infected pacemaker

Explantation of left-sided pacemaker
Explantation of left-sided lead
AV sequential pacemaker inserted in the right subclavian area

Indications: Infected pacemaker with need for AV nodal pacing backup

Method: The patient was brought to the Cath Lab in the post-absorbed state. IVs were pre-established?Sa02, heart rate, heart rhythm and blood pressure monitored. The right subclavian area was prepped and draped in the usual sterile fashion after local anesthesia. Sharp and dull dissections were carried out to the prepectoral fascia utilizing cautery to control hemostasis. A pocket was formed utilizing cautery cutting and coagulation. Puncture x 2 of the right subclavian vein was performed, and sheath and dilator system was utilized to place the leads into the right ventricular apex and right atrium. R-waves were sensed at 8 millivolts. P-waves were sensed at 2.8 millivolts. Impedance to pacing in the ventricle was 1,092 ohms and in the atrium 657 ohms. Threshold in the atrium was 1 volt and in the ventricle 1.8 volts. Each lead was sutured in place x 2 with 0 silk sutures. The lead device was placed on the lead, and the pocket was irrigated and the device placed in the pocket. The pocket was closed with a running 2-0 Vicryl subcutaneous and subcuticular 4-0 Vicryl. Sponge and needle counts were correct. The patient tolerated the procedure well.

The left subclavian area then was exposed. After local, the preexisting pacemaker was explanted. Cultures were obtained. The preexisting left-sided lead had traction applied, and it was explanted easily. The pocket was then irrigated. The necrotic tissue was excised. A 2-0 running Vicryl subcutaneous stitch was implanted, and a 4-0 Vicryl was utilized to approximate the skin. Instrument, sponge and needle counts were correct. The patient tolerated the procedure well.
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