jtuominen
Guru
Hi there-- This case has been challenging many of the coders in our department. I am about ready to send it back for addendum, but I thought I would post it to see if anyone else can make sense of what exactly was performed here. So far I have
93613
93652
And Im leaning towards
93600
93603
I don't think it meets criteria for 93620 at all.
Please help!
PROCEDURES PERFORMED:
1. EP study with induction of ventricular tachycardia.
2. 3D intracardiac mapping.
3. Ablation of the left ventricular tachycardia.
INDICATION FOR PROCEDURE: Patient is a 69-year-old white male
with a history of coronary artery disease and severe LV dysfunction.
He had a previous VT ablation which reduced the number of ICD shocks.
However, over the recent few months, the patient started to have
increasing frequency of ICD shocks from once a week to almost daily
in the last few days. He has been on antiarrhythmic drug therapy
without success. After the risks and benefits of the procedure were
explained the patient consented for a repeat ablation.
PROCEDURE AND RESULTS: After the written informed consent was
obtained, the patient was transported to CV Lab 4 in the fasting
state. The procedure was performed under local anesthesia and
sterile conditions. IV Versed and fentanyl were used for conscious
sedation. By using the Seldinger technique, a 6 French quadripolar
catheter was inserted through the right femoral vein and positioned
into the RV apex for induction of VT. The ESI balloon mapping
catheter was inserted through the left femoral artery and positioned
into the left ventricle. The ablation catheter was an 8 mm EPT that
was inserted through the right femoral artery and positioned into the
LV. The patient received heparinization after the access of the
femoral artery.
He was in sinus rhythm with first degree AV block and left bundle
branch block at the baseline. There were frequent PVCs of single
morphology. The PVC was mapped to the upper left ventricular septum.
The patient has a very large left ventricle which was beyond the
mapping range of the balloon mapping catheter. The mapping and
ablation was guided by the Array mapping system. The left ventricle
geometry was collected by using the ablation catheter and the balloon
mapping catheter. It was observed that extensive scar was present
over the left ventricle. The only viable myocardial area was the
anterior lateral basal LV where the epicardial left ventricular
pacing lead was placed.
The patient had multiple very wide QRS VTs with different rates in
QRS morphologies. The VTs were induced by triple ventricular
extrastimuli and on one occasion by catheter manipulation. None of
the VT was pace terminable. The conventional mapping and balloon
mapping both indicated origin of the VTs from the apical septal area
near the border of the scar.
Due to the unstable status of the VT the ablation was performed along
the border of the scar. A linear lesion was created from the apical
septum up to the anterior septum just below the level of the His
bundle. None of the ablations were applied in the healthy
myocardium. Furthermore, the ablation was extended in the
anterolateral apical toward the apical septum. The PVC at baseline
disappeared during the ablation procedure. Due to the close location
of those PVCs to the His bundle region no ablation was applied to the
basal left ventricular septum.
After the ablation of the left ventricular anterior septum, the
patient had continued induction of VT of at least two types. None of
them was terminable by pacing but the rate seemed to be slowed down
to about 170 beats per minute.
Due to the extensive scar tissue, low ejection fraction and the long
procedure time it was decided to abort the ablation for concern of
complications.
At the end of the procedure, the catheters and sheaths were removed
and local pressure was applied to the puncture sites. The pacing
rate was increased to 80 beats per minute in order to suppress the
PVC and hopefully will reduce the incidence of VT empirically.
Otherwise, there was no complication.
For the short time being, sotalol will be continued at the same
dosage. Mexiletine is discontinued because of the complaint of severe
stomach upset. If he improves clinically with ventricular arrhythmia
the dosage of sotalol may be reduced.
93613
93652
And Im leaning towards
93600
93603
I don't think it meets criteria for 93620 at all.
Please help!
PROCEDURES PERFORMED:
1. EP study with induction of ventricular tachycardia.
2. 3D intracardiac mapping.
3. Ablation of the left ventricular tachycardia.
INDICATION FOR PROCEDURE: Patient is a 69-year-old white male
with a history of coronary artery disease and severe LV dysfunction.
He had a previous VT ablation which reduced the number of ICD shocks.
However, over the recent few months, the patient started to have
increasing frequency of ICD shocks from once a week to almost daily
in the last few days. He has been on antiarrhythmic drug therapy
without success. After the risks and benefits of the procedure were
explained the patient consented for a repeat ablation.
PROCEDURE AND RESULTS: After the written informed consent was
obtained, the patient was transported to CV Lab 4 in the fasting
state. The procedure was performed under local anesthesia and
sterile conditions. IV Versed and fentanyl were used for conscious
sedation. By using the Seldinger technique, a 6 French quadripolar
catheter was inserted through the right femoral vein and positioned
into the RV apex for induction of VT. The ESI balloon mapping
catheter was inserted through the left femoral artery and positioned
into the left ventricle. The ablation catheter was an 8 mm EPT that
was inserted through the right femoral artery and positioned into the
LV. The patient received heparinization after the access of the
femoral artery.
He was in sinus rhythm with first degree AV block and left bundle
branch block at the baseline. There were frequent PVCs of single
morphology. The PVC was mapped to the upper left ventricular septum.
The patient has a very large left ventricle which was beyond the
mapping range of the balloon mapping catheter. The mapping and
ablation was guided by the Array mapping system. The left ventricle
geometry was collected by using the ablation catheter and the balloon
mapping catheter. It was observed that extensive scar was present
over the left ventricle. The only viable myocardial area was the
anterior lateral basal LV where the epicardial left ventricular
pacing lead was placed.
The patient had multiple very wide QRS VTs with different rates in
QRS morphologies. The VTs were induced by triple ventricular
extrastimuli and on one occasion by catheter manipulation. None of
the VT was pace terminable. The conventional mapping and balloon
mapping both indicated origin of the VTs from the apical septal area
near the border of the scar.
Due to the unstable status of the VT the ablation was performed along
the border of the scar. A linear lesion was created from the apical
septum up to the anterior septum just below the level of the His
bundle. None of the ablations were applied in the healthy
myocardium. Furthermore, the ablation was extended in the
anterolateral apical toward the apical septum. The PVC at baseline
disappeared during the ablation procedure. Due to the close location
of those PVCs to the His bundle region no ablation was applied to the
basal left ventricular septum.
After the ablation of the left ventricular anterior septum, the
patient had continued induction of VT of at least two types. None of
them was terminable by pacing but the rate seemed to be slowed down
to about 170 beats per minute.
Due to the extensive scar tissue, low ejection fraction and the long
procedure time it was decided to abort the ablation for concern of
complications.
At the end of the procedure, the catheters and sheaths were removed
and local pressure was applied to the puncture sites. The pacing
rate was increased to 80 beats per minute in order to suppress the
PVC and hopefully will reduce the incidence of VT empirically.
Otherwise, there was no complication.
For the short time being, sotalol will be continued at the same
dosage. Mexiletine is discontinued because of the complaint of severe
stomach upset. If he improves clinically with ventricular arrhythmia
the dosage of sotalol may be reduced.