My biller is trying to code this, when she questioned MD about doing a 93620, he stated that he did do a coronary angio though. Since 93621, 93622, and 93623 can only be billed with a 93620, does anyone have any advise?
Procedures:
Right ventricular pacing and recording
Left ventricular pacing and recording
His bundle measurements
Infusion of isoproterenol and programmed stimulation
Left heart cath via transeptal puncture
Coronary angiography
Radiofrequency catheter ablation of a ventricular tachycardia focus
Left atrial pacing recording from the the coronary sinus
After informed consent the patient was brought to the EP lab where she was sedated prepped and draped. Once she was adequately sedated the area over the right and left femoral regions were infiltrated with lidocaine. Sheaths were placed, 2 in the right femoral vein and one in the left femoral vein and connected to continuous heparinized saline solution. A 5 french sheath was placed in the right femoral artery for arterial blood pressure monitoring during the case. Once all sheaths were in position I placed the following catheters, an intracardiac ultrasound catheter was positioned in the right atrium. We created a 3 dimensional map of the the left ventricle as well as the aortic outflow tract. We also placed a quadripolar catheter in the right ventricle for pacing and recording from this area. Once we had a 3 dimensional map created of the left ventricle we then turned our attention to transeptal puncture as the PVC's, which were frequent at that point, were right bundle branch with an inferior axis negative in lead 1 and thought we would be mapping the left ventricle so we visualized the interatrial septum. We used a Mullins sheath, I attempted to use a 3-D mapping system, but the motor on the drive unit failed, therefore had to use a manual approach. The Mullins sheath was placed on the high right atrium with a Brockenbrough needle connected to a transduced pressure line. This was dragged back back to the interatrial septum. The septum was tented under direct intracardiac ultrasonic guidance. The needle was then extruded, noting left atrial pressure. Once left atrial pressure was noted the dilators were advanced over the needle into the left atrium. Once we had access to the left atrium a 3.5 mm irrigated tip catheter was then used to map the left ventricle. We did the left ventricle pace mapping, found the area of earliest activation to be the anterolateral portion of the basal segment of the LV. Activation times in this area were at the onset or slightly earlier than the onset of the QRS complex. We put some empiric lesions here with no influence on the tachycardia. At that point we decided to map the coronary sinus. I first used the quadripolar catheter and placed this in the coronary sinus. We paced the LA and the LV from the coronary sinus. Pace maps were nearly identical from the distal coronary sinus, 98% pace map match based upon the software. At that point the irrigated tip catheter was then taken out of the LV and placed in the RV and we cannulated the coronary sinus. At this site we mapped earliest activation of the VT and PVC focus, and once again did pace mapping. We then, due to the location of the distal coronary sinus, performed an angiogram to determine the distance from the coronary artery. We were 1 cm away from any branch of the coronary artery and decided to administer lesions in this area. We started at 15 watts and titrated up to 30 watts. We did have sensation of VT for a few seconds, but it would immediately return. At this point it pretty clear that this was an epicardial focus and decided to terminate the case. A final coronary angiogram was done whiuch showed no damage to the coronary left circulation and the catheters were then removed.
Conclusion: Unsuccessful catheter ablation for PVC's/VT focus emanating from the LV epicardium.
Procedures:
Right ventricular pacing and recording
Left ventricular pacing and recording
His bundle measurements
Infusion of isoproterenol and programmed stimulation
Left heart cath via transeptal puncture
Coronary angiography
Radiofrequency catheter ablation of a ventricular tachycardia focus
Left atrial pacing recording from the the coronary sinus
After informed consent the patient was brought to the EP lab where she was sedated prepped and draped. Once she was adequately sedated the area over the right and left femoral regions were infiltrated with lidocaine. Sheaths were placed, 2 in the right femoral vein and one in the left femoral vein and connected to continuous heparinized saline solution. A 5 french sheath was placed in the right femoral artery for arterial blood pressure monitoring during the case. Once all sheaths were in position I placed the following catheters, an intracardiac ultrasound catheter was positioned in the right atrium. We created a 3 dimensional map of the the left ventricle as well as the aortic outflow tract. We also placed a quadripolar catheter in the right ventricle for pacing and recording from this area. Once we had a 3 dimensional map created of the left ventricle we then turned our attention to transeptal puncture as the PVC's, which were frequent at that point, were right bundle branch with an inferior axis negative in lead 1 and thought we would be mapping the left ventricle so we visualized the interatrial septum. We used a Mullins sheath, I attempted to use a 3-D mapping system, but the motor on the drive unit failed, therefore had to use a manual approach. The Mullins sheath was placed on the high right atrium with a Brockenbrough needle connected to a transduced pressure line. This was dragged back back to the interatrial septum. The septum was tented under direct intracardiac ultrasonic guidance. The needle was then extruded, noting left atrial pressure. Once left atrial pressure was noted the dilators were advanced over the needle into the left atrium. Once we had access to the left atrium a 3.5 mm irrigated tip catheter was then used to map the left ventricle. We did the left ventricle pace mapping, found the area of earliest activation to be the anterolateral portion of the basal segment of the LV. Activation times in this area were at the onset or slightly earlier than the onset of the QRS complex. We put some empiric lesions here with no influence on the tachycardia. At that point we decided to map the coronary sinus. I first used the quadripolar catheter and placed this in the coronary sinus. We paced the LA and the LV from the coronary sinus. Pace maps were nearly identical from the distal coronary sinus, 98% pace map match based upon the software. At that point the irrigated tip catheter was then taken out of the LV and placed in the RV and we cannulated the coronary sinus. At this site we mapped earliest activation of the VT and PVC focus, and once again did pace mapping. We then, due to the location of the distal coronary sinus, performed an angiogram to determine the distance from the coronary artery. We were 1 cm away from any branch of the coronary artery and decided to administer lesions in this area. We started at 15 watts and titrated up to 30 watts. We did have sensation of VT for a few seconds, but it would immediately return. At this point it pretty clear that this was an epicardial focus and decided to terminate the case. A final coronary angiogram was done whiuch showed no damage to the coronary left circulation and the catheters were then removed.
Conclusion: Unsuccessful catheter ablation for PVC's/VT focus emanating from the LV epicardium.
