espressoguy
Guest
I'm a little perplexed as to whether this would be coded as a straightforward 33208 or if this might warrant a modifier 22 or whether some else could be coded.
DESCRIPTION OF TECHNIQUE: After informed consent, the patient was taken to the operating room where the upper chest was prepped and draped in the usual sterile fashion. Lidocaine 1% was used as a local anesthesia. A 5 cm incision was made one fingerbreadth below the left clavicle and carried down to the pectoralis fascia where a generator pocket was created anterior to the pectoralis muscle. The left subclavian vein was cannulated with a micropuncture needle. However, the guidewire would not pass the midline. With concerns over this was arterial, dissection was carried out in the deltopectoral groove and the cephalic vein isolated. The guidewire passed to the cephalic vein would not pass beyond the proximal subclavian vein. Subclavian venography was then performed revealing the presence of a left superior vena cava eliminating the possibility of a left-sided implant. The wound was closed with a deep layer of 3-0 and a subcuticular layer of 4-0 Vicryl. The right side was prepped and draped in the usual sterile fashion. The aforementioned process was repeated with formation of a pocket anterior to the pectoralis muscle. Using a micropuncture kit, and a 19-gauge thin-walled needle, the right subclavian vein was cannulated and 2 short J guidewires passed the right heart under fluoroscopic guidance. A bipolar active fixation pacing lead was passed to the RV apex (Medtronic 5076-58). This proved to be difficult because of long periods of pauses related to mechanical ectopy. Ultimately, the lead needed to be urgently screwed into place in a relatively proximal septal location. Nevertheless, the threshold here, was less than 1 volt. A second 5076 was passed through a 7-French introducer to the atrial appendage (serial # PJN 406877). Both leads were then secured with 2 separate 0 Ethibond stitches each. The leads were connected to the pulse generator (Medtronic advisor, serial #PBY362978H). At this point, loss of capture on the ventricular lead was documented. Leads were freed up emergently. The right atrial lead was unscrewed and advanced into the right ventricle as a temporary pacing lead. The right ventricular lead was then repositioned. A traditional apical location was chosen. Here, the impedance was 617 ohms, and the threshold was 0.6 V. The atrial lead was then unscrewed and withdrawn to the right atrium where it was positioned in the appendage. Threshold here was 0.9 V with a 3.9 mV P wave and an impedance of 688 ohms. Both leads were secured with 2 separate 0 Ethibond stitches each and connected back to the pulse generator, which was secured with a single 0 Ethibond stitch. The pocket was irrigated with antibiotic solution and closed with a deep layer of 3-0 Vicryl and a subcuticular layer of 4-0 Vicryl. Steri-Strips and a dressing were applied. The patient was sent to recovery in stable condition/
TIA
DESCRIPTION OF TECHNIQUE: After informed consent, the patient was taken to the operating room where the upper chest was prepped and draped in the usual sterile fashion. Lidocaine 1% was used as a local anesthesia. A 5 cm incision was made one fingerbreadth below the left clavicle and carried down to the pectoralis fascia where a generator pocket was created anterior to the pectoralis muscle. The left subclavian vein was cannulated with a micropuncture needle. However, the guidewire would not pass the midline. With concerns over this was arterial, dissection was carried out in the deltopectoral groove and the cephalic vein isolated. The guidewire passed to the cephalic vein would not pass beyond the proximal subclavian vein. Subclavian venography was then performed revealing the presence of a left superior vena cava eliminating the possibility of a left-sided implant. The wound was closed with a deep layer of 3-0 and a subcuticular layer of 4-0 Vicryl. The right side was prepped and draped in the usual sterile fashion. The aforementioned process was repeated with formation of a pocket anterior to the pectoralis muscle. Using a micropuncture kit, and a 19-gauge thin-walled needle, the right subclavian vein was cannulated and 2 short J guidewires passed the right heart under fluoroscopic guidance. A bipolar active fixation pacing lead was passed to the RV apex (Medtronic 5076-58). This proved to be difficult because of long periods of pauses related to mechanical ectopy. Ultimately, the lead needed to be urgently screwed into place in a relatively proximal septal location. Nevertheless, the threshold here, was less than 1 volt. A second 5076 was passed through a 7-French introducer to the atrial appendage (serial # PJN 406877). Both leads were then secured with 2 separate 0 Ethibond stitches each. The leads were connected to the pulse generator (Medtronic advisor, serial #PBY362978H). At this point, loss of capture on the ventricular lead was documented. Leads were freed up emergently. The right atrial lead was unscrewed and advanced into the right ventricle as a temporary pacing lead. The right ventricular lead was then repositioned. A traditional apical location was chosen. Here, the impedance was 617 ohms, and the threshold was 0.6 V. The atrial lead was then unscrewed and withdrawn to the right atrium where it was positioned in the appendage. Threshold here was 0.9 V with a 3.9 mV P wave and an impedance of 688 ohms. Both leads were secured with 2 separate 0 Ethibond stitches each and connected back to the pulse generator, which was secured with a single 0 Ethibond stitch. The pocket was irrigated with antibiotic solution and closed with a deep layer of 3-0 Vicryl and a subcuticular layer of 4-0 Vicryl. Steri-Strips and a dressing were applied. The patient was sent to recovery in stable condition/
TIA