bennieyoung
Guru
I am being audited and questioned about the CPT codes that I used. I used 33225, 33229, 93619. The auditor disagrees with me and I would like if someone can look and give me their opinion as to which codes are needed. I have attached the report and appreciate any help with this!
BIV PACEMAKER UPGRADE
Diagnostic EP Studies
Indications
VT (ventricular tachycardia) [I47.2 (ICD-10-CM)]
Atrioventricular block, complete (CMS/HCC) [I44.2 (ICD-10-CM)]
Pacemaker [Z95.0 (ICD-10-CM)]
Pre Procedure Diagnosis
VT (ventricular tachycardia) [I47.2]Atrioventricular block, complete (CMS/HCC) [I44.2]Pacemaker [Z95.0]
Procedure
EP study with programmed ventricular stimulation
Indication symptomatic nonsustained ventricular tachycardia
Patient was brought to the EP lab and prepped in the usual manner for EP study. Left axillary vein, subclavian vein found to be patent with venogram. Patient was placed on mechanical ventilation. Right femoral vein access was obtained x1 under ultrasound guidance. A quadripolar catheter was guided to the right ventricle under fluoroscopic guidance. Ventricular program stimulation was performed. Initially a drive train of 600 milliseconds followed by triple extra stimulate down to refractory was performed. This was repeated with a drive train of 400 milliseconds. No VT could be induced.
VERP 400, to 280, 270, 260
Procedure
BIV pacemaker upgrade
Indication
Complete heart block, paced QRS 180ms
Chronic congestive heart failure, NYHA class 3
LV systolic dysfunction, LVEF 40%
The left pectoral region was prepped in the usual manner. Local lidocaine was administered. Under ultrasound guidance the left axillary vein was cannulated with 1 stick. A short 9 French sheath was placed over the wire. A multipurpose Biotronik outer sheath was placed into the right heart over an angled Glidewire. The coronary sinus was cannulated. A balloon contrast venogram was performed. A lateral coronary sinus branch was visualized originating off the distal great cardiac vein. This branch was cannulated with the angled glidewire and the coronary mailman wire. An S curve coronary sinus lead was passed over the wire into the branch. Unfortunately the CS delivery system pulled out of the coronary sinus due to lack of support. At this time another attempt was performed using a sub selector however also failed. The multipurpose outer sheath was exchanged for an extended hook sheath. The same branch was eventually recannulated with the mailman coronary wire. At this time in L curve CS lead was tracked over the wire into the branch. Pacing and sensing characteristics were checked. There was phrenic stim at 10 volts however this disappeared at 7.5 volts. Threshold was acceptable. At this time an incision was made into the pre-existing pocket. Hemostasis was achieved using electrocautery. The pocket was entered.
The CS delivery sheath was then slit under fluoroscopic guidance. The lead did pullback approximately 1 cm however remains stable with acceptable lateral positioning and threshold within acceptable limits.
The new generator was then attached to the new CS lead. The existing atrial and RV leads were then detached from the existing pulse generator and attached to the new generator using the provided tool.
The pocket was irrigated copiously with antibiotic solution.
The generator was placed in the pocket with the leads coiled underneath. It was tied down to the floor of the pocket with 0 Ethibond.
Tyrx was placed around the device.
The incision was closed with 2-0 and 4-0 Vicryl.
Dermabond was placed over the incision. A light pressure dressing was placed over the wound. There is no pneumothorax on fluoroscopy. The patient was transferred to a monitored bed in stable condition.
Company Model number
Explanted pulse generator Biotronik
Pulse generator Biotronik
Right ventricular lead Biotronik
The right atrial lead Biotronik
Left ventricular Biotronik
Sensing Threshold Impedance
LV lead - 1-2
0.6 a t0.4 624
RV lead - 0.9 at 0.4 448
RA lead 4 0.8 at 0.4 429
Device programming
DDDCLS 60/130
Assessment and plan:
Noninducible for sustained VT during the stim
Status post successful CRT P upgrade
Chest x-ray in the recovery area
Antibiotics x1 week
Follow-up in device clinic as scheduled
BIV PACEMAKER UPGRADE
Diagnostic EP Studies
Indications
VT (ventricular tachycardia) [I47.2 (ICD-10-CM)]
Atrioventricular block, complete (CMS/HCC) [I44.2 (ICD-10-CM)]
Pacemaker [Z95.0 (ICD-10-CM)]
Pre Procedure Diagnosis
VT (ventricular tachycardia) [I47.2]Atrioventricular block, complete (CMS/HCC) [I44.2]Pacemaker [Z95.0]
Procedure
EP study with programmed ventricular stimulation
Indication symptomatic nonsustained ventricular tachycardia
Patient was brought to the EP lab and prepped in the usual manner for EP study. Left axillary vein, subclavian vein found to be patent with venogram. Patient was placed on mechanical ventilation. Right femoral vein access was obtained x1 under ultrasound guidance. A quadripolar catheter was guided to the right ventricle under fluoroscopic guidance. Ventricular program stimulation was performed. Initially a drive train of 600 milliseconds followed by triple extra stimulate down to refractory was performed. This was repeated with a drive train of 400 milliseconds. No VT could be induced.
VERP 400, to 280, 270, 260
Procedure
BIV pacemaker upgrade
Indication
Complete heart block, paced QRS 180ms
Chronic congestive heart failure, NYHA class 3
LV systolic dysfunction, LVEF 40%
The left pectoral region was prepped in the usual manner. Local lidocaine was administered. Under ultrasound guidance the left axillary vein was cannulated with 1 stick. A short 9 French sheath was placed over the wire. A multipurpose Biotronik outer sheath was placed into the right heart over an angled Glidewire. The coronary sinus was cannulated. A balloon contrast venogram was performed. A lateral coronary sinus branch was visualized originating off the distal great cardiac vein. This branch was cannulated with the angled glidewire and the coronary mailman wire. An S curve coronary sinus lead was passed over the wire into the branch. Unfortunately the CS delivery system pulled out of the coronary sinus due to lack of support. At this time another attempt was performed using a sub selector however also failed. The multipurpose outer sheath was exchanged for an extended hook sheath. The same branch was eventually recannulated with the mailman coronary wire. At this time in L curve CS lead was tracked over the wire into the branch. Pacing and sensing characteristics were checked. There was phrenic stim at 10 volts however this disappeared at 7.5 volts. Threshold was acceptable. At this time an incision was made into the pre-existing pocket. Hemostasis was achieved using electrocautery. The pocket was entered.
The CS delivery sheath was then slit under fluoroscopic guidance. The lead did pullback approximately 1 cm however remains stable with acceptable lateral positioning and threshold within acceptable limits.
The new generator was then attached to the new CS lead. The existing atrial and RV leads were then detached from the existing pulse generator and attached to the new generator using the provided tool.
The pocket was irrigated copiously with antibiotic solution.
The generator was placed in the pocket with the leads coiled underneath. It was tied down to the floor of the pocket with 0 Ethibond.
Tyrx was placed around the device.
The incision was closed with 2-0 and 4-0 Vicryl.
Dermabond was placed over the incision. A light pressure dressing was placed over the wound. There is no pneumothorax on fluoroscopy. The patient was transferred to a monitored bed in stable condition.
Company Model number
Explanted pulse generator Biotronik
Pulse generator Biotronik
Right ventricular lead Biotronik
The right atrial lead Biotronik
Left ventricular Biotronik
Sensing Threshold Impedance
LV lead - 1-2
0.6 a t0.4 624
RV lead - 0.9 at 0.4 448
RA lead 4 0.8 at 0.4 429
Device programming
DDDCLS 60/130
Assessment and plan:
Noninducible for sustained VT during the stim
Status post successful CRT P upgrade
Chest x-ray in the recovery area
Antibiotics x1 week
Follow-up in device clinic as scheduled
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