Question EP coding additional ablation documentation- 93655

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Millington, MI
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Good morning,
I have a provider that is questioning the additional ablation code CPT 93655

93655 for CTI or right/left side atrial flutter after a fib ablation. Other examples include ablation of AVNRT or AVRT/ WPW discovered during the procedure. Target of an SVT after addressing a ventricular focus in the same setting.

Understanding in this procedure that there was No arrhythmia was inducible by end of the procedure nor was there any additional discovered after the ablation-
I have coded the following,

93613
93662-26
93656
92960-59

Procedure indications:

Persistent AF. The arrhythmia is refractory to rate control and/or anti-arrhythmic drugs.

Procedure summary:

After written witnessed informed consent was obtained for the procedure and sedation from the patient, the patient was transferred to the EP Lab. The procedure was performed in the post absorptive state off all anti-arrhythmic drugs. A grounding pad was placed. Self-adhesive anterior-posterior defibrillation pads were applied. Blood pressure was monitored.

The groins were prepped and draped in the usual sterile fashion.

Transesophageal Echo was done and LAA thrombus was ruled out

Local anesthesia with Bupivacaine 0.25 % was given.

U/S guided peripheral intravenous access was obtained. The vessel was accessed using the modified Seldinger technique.

A multi-electrode catheter containing a set of 10 electrodes (spanning the coronary sinus) was positioned via the right FV.

Intracardiac echocardiography. A transducer was advanced into the right atrium via the sheath in the right femoral vein. Echocardiography was used to guide the transseptal puncture, guide positioning of the ablation tip electrode at the target sites, ensure proper contact between the ablation catheter and the endocardium, identify potential complications, and image the LA and pulmonary veins (PV).

Transseptal catheterization was performed under fluoroscopic and intracardiac echocardiographic guidance. Heparin bolus and continuous IV infusion were given prior transseptal puncture/ catheterization. The sheath in the right femoral vein was exchanged over a wire. A transseptal access was performed using a SL1/Brockenbrough needle assembly. Once transseptal access was performed, a multi-electrode catheter was advanced through the long sheath and positioned in the left superior pulmonary vein. The heparin infusion rate was adjusted to maintain an ACT between 350-400 sec throughout the procedure.

Electrophysiologic testing was performed. Measurements of basic intervals were obtained. Stimuli were delivered at coronary sinus sites.

3-D electro-anatomic mapping. The pulmonary veins and left atrium sites were mapped, making use of Biosense Webster (J&J) Carto System.

RF ablation was performed. Follow-up testing was performed 30 minutes post ablation.

Sheaths were removed. A figure of 8 suture was placed. Adequate hemostasis was obtained.


Vascular access and catheter properties:

Entry site
Locations
Catheter
R femoral vein​
Mid RA​
Intra-cardiac Echo SoundStar 8F​
R femoral vein​
Coronary sinus​
SJM CS catheter 6F​
R femoral vein​
Trans-septal Multielectrode
BS PentaRay Catheter​
R femoral vein​
Trans-sept alablation catheter​
ThermoCool Smart Touch-SF BiDirectional D-F​


Administered medications:


The procedure was performed under GA.



Contrast N/A cc
Bupivicaine, subcutaneously



Arrhythmia:
Arrhythmia 1:
The patient was in AF at start of the procedure. The LA was mapped using Penta-Ray D care during AF. There were two left PVs and two right PVs. There was moderate scar around the veins,posterior wall, roof and anterior wall of the left atrium. Once mapping was done, transseptal sheaths was exchanged for a VisiGo steerable sheath.

Ablation of the pulmonary veins was done with a WACA and a Carina line in each side, while monitoring esophageal temperature closely during ablation. Isolation of the left and right pulmonary veins was accomplished. DCC was done with 200 joules with restoration of NSR. There was evidence of entrance block by end of the procedure.

Arrhythmia 2:
There was extensive is scar involving the posterior wall. There were significant premature atrial beats and nonsustained atrial tachycardia from the posterior wall. Posterior wall was then isolated with the roof line and a floor line in a box fashion connecting to the WACAs bilateral. Exit block confirmed by pacing from the isolated posterior wall. Additional ablation were done using "pace-and- ablate" strategy. Esophageal temperature was closely monitored during ablation of the posterior wall. At the end, there was evidence of entrance & exit block.


Rapid atrial pacing down to CL 250 ms did not induce any flutter or further arrhythmias.

Following ablation and EP study was performed, PR= 187 ms, RR= 884 ms, QRS=84 ms, QT=381 ms:
AH= 78 ms, HV=52 ms. AVNERP= 500/310 ms, AVBCL 390 ms. There was evidence of dual AV node physiology. No arrhythmia was inducible.



Lesions:


Radiofrequency lesion summary:

Multiple applications of variable duration were delivered.



Complications:

No complications.



Discharge and follow-up:

The patient left the EP laboratory in stable condition.



The patient will remain in the hospital overnight for observation and rest, with anticipated discharge on the following day. The patient has been instructed accordingly.



Summary:

Successful RF AF ablation with isolation of all 4 pulmonary veins, with evidence of entrance block.

Successful ablation of the posterior wall for non-sustained AT with posterior wall isolation

Evidence for dual AV node physiology on electrophysiology study. No arrhythmia was inducible by end of the procedure.
 
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