Question Help coding RV lead extraction, new RV lead implant and His lead implant for biventricular pacemaker

jthahn@tds.net

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Millington, MI
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Hello,
If anyone can help look at this report, to make sure I have captured all the correct codes,
I have CPT - 33208, 33234, 33225,

the Doctor has
33216, 33233, 33224, 33234, 93662, 33244

Thank you in advance,

· RV lead Laser Lead Extraction
· RV lead implant
· LV lead implant
· Biv Pacemaker Implant
· Pocket Revision
· Device re-implant
· Temporary Pacer Placement
· Intra-cardiac Echo (ICE)


Indication:
Patient with PPM implanted in 2006 for CHB, developed non-ischemic CMP with CHF NYHA class II symptoms, with severe TR, severe LV systolic dysfunction EF 30% comes in for RV lead extraction for lead-related severe TR (lead entrapped leaflet) along with device upgrade to Biv-PPM due to his Pacing-induced cardiomyopathy.

Complications:
No complications

Blood Loss:
20 cc

Contrast:
None


Procedure #1 : RV LEAD EXTRACTION:

The cardiothoracic teams were informed of all extractions in advance and on standby in the event of any major complications. A 4 units of PRBCs were typed and crossed and made readily available in the procedure room. External patches that permit transcutaneous pacing and defibrillation was placed on the patient outside of the sterile working field. Device was reprogrammed VOO to enable asynchronous pacing, when appropriate once the patient is connected to a cardiac monitor .Patient underwent general endotracheal anesthesia. BP was monitored via an arterial line in the radial artery. Intracardiac echo (ICE) was placed for monitoring of complications. A 14 F venous sheath was placed and an occlusive compliant balloon was advanced to the SVC and then retracted down to the IVC. A temporary pacing catheter was placed via a 6F sheath in the RV for pacing if needed.

The anterior chest, left subclavian area and bilateral groins was prepped and draped in the standard sterile fashion for possible emergent sternotomy. Local anesthesia was administered to the left anterior chest wall prior to opening the pocket. The device generator pocket was opened using a blade and the leads were freed by surgical dissection down to the venous insertion site as far as possible. The leads were cut 10 cm out of the venous entry site. A normal stiff straight stylet of appropriate length was inserted to clear the lead lumen. The active fixation mechanism was retracted for the RV lead which was non-retractable. An initial attempt was then made at direct gentle manual traction. This was unsuccessful, an appropriately sized locking stylet was then inserted and a suture was tied from the insulation of the lead to the locking stylet. A repeat attempt at manual traction was then made. This again failed to result in successful extraction, we then a 14F Laser/Mechanical dissecting sheaths was advanced over the prepped lead. This was able to fully extract the RV lead in its entirety.

Following extraction, the device pocket hemostasis was controlled. Irrigation of the pocket with antibiotics solution was done before closing the pocket in two layers. ICE showed no evidence of effusion and intact tricuspid valve.



Procedure #2: RV Lead Re-Implant & Biv PPM Upgrade:

RV Lead Implant:
A peel away sheath was brought to the field and placed into the venous system via over the wire technique. The right ventricular lead was placed via this sheath into the right ventricle under fluoroscopy. The lead was attached via active fixation to the distal RV septum. Adequate sensing and threshold parameters were obtained. There was no evidence of diaphragmatic stimulation at 10 V output. The peel away sheath was removed and the lead collar was advanced to the pectoral muscle and sutured with non absorbable suture. Stability of the lead and the length of the lead's slack was assessed as optimal with fluoroscopy.

LV lead Implant
A 9.0 French sheath was then passed over the guide wire and the guide wire removed. a multi purpose guiding catheter was introduced and engaged with the coronary sinus. Engaging the CS with a wire was difficult due to the very dilated right atrium the vertical takeoff of the coronary sinus which made support very poor, once this accomplished a venogram was done, the coronary sinus was very dilated.
A balloon tip catheter was used to perform coronary sinus angiogram and identify CS branches. The patient has a very large posterior branch, we placed the LV lead on this dilated posterior branch the lead has very poor capture threshold. It also has very close proximity to the RV lead will likely be none helpful for the patient. We then went with a basal anterolateral branch which also has very limited capture options with a relatively high threshold.

After placing the LV lead and while removing the CS support sheath the lead dislodged. It appears the vertical takeoff of the coronary sinus resulted in kinking of the CS access sheath which made it difficult to remove the CS sheath without concomitant pulling the LV lead. Given the multiple trials of placing LV lead we decided to proceed with placement of a HIS lead.

His Lead implant :
The fixed-curve C315 His sheath was advanced over the guide wire to the RA. The His bundle was mapped using the pacing lead (Select-Secure 3830) in a unipolar fashion.
Pacing is performed at 5 V at 1 ms to verify His capture. Twelve-lead electrocardiograms are displayed along with His electrograms during mapping and pacing. The pacing lead is slowly rotated clockwise and secured to the HIS location. The sheath is withdrawn to the high right atrium until an adequate slack is formed. Pacing thresholds are then checked in both unipolar and bipolar configurations. The S-QRS is consistent with non-selective His capture. The peel away sheath was removed with splitting and the lead collar was advanced to the pectoral muscle and sutured with non absorbable suture. Stability of the lead and the length of the lead's slack was assessed as optimal with fluoroscopy.

There were no complications, patient tolerated the procedure well. The patient left the EP lab in stable condition.


Impression:
1) Successful Laser/mechanical cutting sheath Leads extraction of RV lead
2) Successful implant of new RV lead
3) Successful implant of biventricular pacemaker with addition LV/HIS lead and of Bivpacemaker generator
 
Hi ,

These are my codes if for BiV Pacemaker : 33234, 33207, 33225, 33233, 93662

1. Successful Laser/mechanical cutting sheath Leads extraction of RV lead - 33234
2. Successful implant of new RV lead - 33207 (Ventricular lead)
3. Successful implant of biventricular pacemaker with addition LV/HIS lead and of BiV pacemaker generator - 33225

And
4. Removal of the Old generator - 33233
5. ICE was used to confirm - 93662


I would check with the provider on below:

A. I feel there is some missing information / confusion ...

- Physician's code is supportive of ICD (defibrillator implant.)
Indication being CMP usually they implant ICD's and not PM .
Although I am not 100% sure on this , Check if this is an upgrade from Dual PM to BiV ICD or BiV PPM!

- The documentation of insertion of BiV pacemaker generator is mentioned only in the impression and not in procedure description.
You have mentioned procedure 2 after the closure of device pocket.....
- It needs to be connected with the New Generator right?...
- Procedure 2 ends with ,"Stability of the lead and the length of the lead's slack was assessed as optimal with fluoroscopy. There were no complications, patient tolerated the procedure well. The patient left the EP lab in stable condition".

B. And do refer the implant record/ table to make sure that a NEW RV lead was used.
(if the same old one was reused ,then it's repositioning and the code will be 33215)



Sorry, I went in depth with the documentation .
But hope this helps .
 
Hi ,

These are my codes if for BiV Pacemaker : 33234, 33207, 33225, 33233, 93662

1. Successful Laser/mechanical cutting sheath Leads extraction of RV lead - 33234
2. Successful implant of new RV lead - 33207 (Ventricular lead)
3. Successful implant of biventricular pacemaker with addition LV/HIS lead and of BiV pacemaker generator - 33225

And
4. Removal of the Old generator - 33233
5. ICE was used to confirm - 93662


I would check with the provider on below:

A. I feel there is some missing information / confusion ...

- Physician's code is supportive of ICD (defibrillator implant.)
Indication being CMP usually they implant ICD's and not PM .
Although I am not 100% sure on this , Check if this is an upgrade from Dual PM to BiV ICD or BiV PPM!

- The documentation of insertion of BiV pacemaker generator is mentioned only in the impression and not in procedure description.
You have mentioned procedure 2 after the closure of device pocket.....
- It needs to be connected with the New Generator right?...
- Procedure 2 ends with ,"Stability of the lead and the length of the lead's slack was assessed as optimal with fluoroscopy. There were no complications, patient tolerated the procedure well. The patient left the EP lab in stable condition".

B. And do refer the implant record/ table to make sure that a NEW RV lead was used.
(if the same old one was reused ,then it's repositioning and the code will be 33215)



Sorry, I went in depth with the documentation .
But hope this helps .
Thank you this definitely helps,

I did verify that this was an upgrade from the Dual PPM, to the BiV PPM with the actual Cardiac Evaluation Sheets for the procedure,
and YES there was a new RV lead as per the Cardiac Evaluation sheets and also the manufacture's Model and Serial numbers.
The explanted and implanted numbers were verified.

I will make a note for the doctor that the documentation needs to state that it was connected, I know that it states it in the other report,
"Generator connected to leads. Paced beats observed".
 
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