Brandi
New
Any help on this would be greatly appreciated!
The doctor planned to do an upgrade from a dual to a mult-lead ICD...that was unsuccessful. The only thing I can bill for is the CS venogram.. which is usually bundled. How do I code a CS venogram alone?
Here's the procedure note:
Procedure Orders:
1. EP UPGRADE DEVICE TO BIV ICD
Pre-procedure Diagnoses
1. CHF (congestive heart failure), NYHA class III, chronic, systolic (HCC) [I50.22]
2. Left bundle branch block (LBBB) [I44.7]
Post-procedure Diagnoses
1. Chronic systolic congestive heart failure (HCC) [I50.22]
2. LBBB (left bundle branch block) [I44.7]
Procedures
1. EP UPGRADE DEVICE TO BIV ICD [EP28 (Custom)]
Procedure: Attempted upgrade to BIV ICD from DDD ICD
Diagnosis: CHF, systolic heart failure (chronic), LBBB (chronic pacing
EP laboratory for upgrade of existing dual chamber ICD to a biventricular ICD. Informed consent was obtained prior to the procedure start and conscious sedation was provided for the procedure by Anesthesia, which is detailed elsewhere. IV antibiotics were given prior to the incision and the left prepectoral area was prepped and draped in usual standard fashion. The area over the incision and pontic were anesthetized with Pontocaine and the incision was opened with a plasma blade. The incision was carried down to the chronic pocket and the leads and pulse generator were liberated. The pulse generator was removed from the pocket and the ICD lead in the right atrial lead were freed of adhesions. Subclavian access was obtained and a wire was passed under fluoroscopic guidance into the central circulation. A Worley sheath was advanced into the right atrium and used to cannulate the coronary sinus. Cs access was challenging and a decapolar coronary sinus diagnostic catheter was used to cannulate the Cs. We could not advance the Worley sheath over the decapolar catheter due to tortuosity at the ostium of the coronary sinus and eventually the Worley sheath was exchanged for a Medtronic and V2 sheath. Once coronary sinus was cannulated, a venogram was performed which showed a very large and ectatic coronary sinus with no anterolateral, mid lateral or posterolateral branches. We used a Whisper wire and a Medtronic 4398-88, serial number QUB 14135 V trying to engage in anterolateral branch to no avail. There was a small mid lateral branch but it was not large enough to hold the lead and we were unable to cannulate anything in the posterolateral circulation this, we withdrew through the Cs sheath. It was decided at this point that we will make an attempt for hiss bundle pacing and the Cs sheath was exchanged for a short 9-French peel-away sheath and a Medtronic 3830-69, serial number LFFO98174 V was advanced in the central circulation. We were unable to gain acceptable capture thresholds along the intraventricular septum or show any clear evidence of hiss bundle capture. At this point in time, it was decided to refer the patient for thoracoscopic LV lead placement. The right atrial lead and right ventricular lead thresholds were checked and impedances were stable from chronic and there was six years left on the Incepta Boston Scientific and Incept ICD-E 163 serial number 104221. The pocket was copiously irrigated with antibiotic solution and hemostasis was obtained. The pocket was closed with 2 layers of absorbable suture and the skin was approximated with Prolene suture. There were no acute complications.
PROCEDURE SUMMARY: Unsuccessful CRT ICD upgrade with plans to refer for surgical lead placement and submuscular pocket revision.
The doctor planned to do an upgrade from a dual to a mult-lead ICD...that was unsuccessful. The only thing I can bill for is the CS venogram.. which is usually bundled. How do I code a CS venogram alone?
Here's the procedure note:
Procedure Orders:
1. EP UPGRADE DEVICE TO BIV ICD
Pre-procedure Diagnoses
1. CHF (congestive heart failure), NYHA class III, chronic, systolic (HCC) [I50.22]
2. Left bundle branch block (LBBB) [I44.7]
Post-procedure Diagnoses
1. Chronic systolic congestive heart failure (HCC) [I50.22]
2. LBBB (left bundle branch block) [I44.7]
Procedures
1. EP UPGRADE DEVICE TO BIV ICD [EP28 (Custom)]
Procedure: Attempted upgrade to BIV ICD from DDD ICD
Diagnosis: CHF, systolic heart failure (chronic), LBBB (chronic pacing
EP laboratory for upgrade of existing dual chamber ICD to a biventricular ICD. Informed consent was obtained prior to the procedure start and conscious sedation was provided for the procedure by Anesthesia, which is detailed elsewhere. IV antibiotics were given prior to the incision and the left prepectoral area was prepped and draped in usual standard fashion. The area over the incision and pontic were anesthetized with Pontocaine and the incision was opened with a plasma blade. The incision was carried down to the chronic pocket and the leads and pulse generator were liberated. The pulse generator was removed from the pocket and the ICD lead in the right atrial lead were freed of adhesions. Subclavian access was obtained and a wire was passed under fluoroscopic guidance into the central circulation. A Worley sheath was advanced into the right atrium and used to cannulate the coronary sinus. Cs access was challenging and a decapolar coronary sinus diagnostic catheter was used to cannulate the Cs. We could not advance the Worley sheath over the decapolar catheter due to tortuosity at the ostium of the coronary sinus and eventually the Worley sheath was exchanged for a Medtronic and V2 sheath. Once coronary sinus was cannulated, a venogram was performed which showed a very large and ectatic coronary sinus with no anterolateral, mid lateral or posterolateral branches. We used a Whisper wire and a Medtronic 4398-88, serial number QUB 14135 V trying to engage in anterolateral branch to no avail. There was a small mid lateral branch but it was not large enough to hold the lead and we were unable to cannulate anything in the posterolateral circulation this, we withdrew through the Cs sheath. It was decided at this point that we will make an attempt for hiss bundle pacing and the Cs sheath was exchanged for a short 9-French peel-away sheath and a Medtronic 3830-69, serial number LFFO98174 V was advanced in the central circulation. We were unable to gain acceptable capture thresholds along the intraventricular septum or show any clear evidence of hiss bundle capture. At this point in time, it was decided to refer the patient for thoracoscopic LV lead placement. The right atrial lead and right ventricular lead thresholds were checked and impedances were stable from chronic and there was six years left on the Incepta Boston Scientific and Incept ICD-E 163 serial number 104221. The pocket was copiously irrigated with antibiotic solution and hemostasis was obtained. The pocket was closed with 2 layers of absorbable suture and the skin was approximated with Prolene suture. There were no acute complications.
PROCEDURE SUMMARY: Unsuccessful CRT ICD upgrade with plans to refer for surgical lead placement and submuscular pocket revision.