crhunt78
Guru
Hello! I used to dabble in Cardiology coding but am not up to par and really need some help with all of these new CPT codes. I am trying to code a pacemaker lead replacement but am not sure which way to go. Here is a copy of the op note:
Following oral and written informed consent, the patient was brought to the OR in a fasted, unsedated state. The presenting heart rhythm was atrial flutter (tcl 300 msec) with variable AV block. The patient was prepared and draped in the usual sterile fashion. The patient received cefazolin 2gram IVPB prior to incising. The patient received general anesthesia via LMA for sedation. Additionally, 2% lidocaine was infiltrated subcutaneously over the left infraclavicular region coincidental to the prior scar. Fluoroscopy was used to indentify anatomical landmarks and the location of the pacemaker pulse generator and pacemaker leads.
"An incision was made using a #10 scalpel coincidental to the prior incision. Blunt dissection and electrocautery were used to enter the pacemaker pocket. The silk suture securing the pulse generator to the floor of the pocket was identified, cut, and removed. The pacemaker pulse generator was removed from the pocket. The leads were disconnected from the pacemaker header and attached to the PSA. The right ventricular lead was found to have a high capture threshold (>8V at 1.5ms) and poor sensing. The right atrial lead had normal sensing and pacing impedance. The atrial flutter tachycardia cycle length was 300 msec. The right atrium was paced at 270 msec and the rhythm converted to sinus. The pacing threshold was then measured (see below).
The silk suture on the RV suture sleeve was cut and removed. A stiff (purple) stylet was inserted into the RV lead. The RV lead was freed by using gentle traction. The RV lead was withdrawn from the patient's body and set aside (It will be sent to Medtronic, Inc for analysis). A venogram was performed using 15cc of iodinated contrast dye x2 injections to demonstrate the location and patency of the left axillary/subclavian vein. Vascular access was obtained with a micropuncture kit using the modified Seldinger technique under fluoroscopic guidance x1. The micropuncture wire was upsized to a 0.35 J wire and a 7Fr sheath was inserted into the left axillary vein and flushed. A new active fix pacemaker lead was placed under fluoroscopic guidance and secured distally in the RV apical septum and proximally to the underlying fascia using O-Ethibond x2. High output pacing confirmed the absence of diaphragmatic capture. The right atrium was paced at 300msec through the PSA and the patient reverted to atrial flutter with variable AV block (presenting heart rhythm).
The pocket was then copiously irrigated with a saline-bacitracin solution. FloSeal was injected into the pocket. There was excellent hemostasis. The pacemaker pulse generator was then re-introduced to the surgical field and connected to the leads. Care was taken to ensure that the leads were securely fastened in the correct positions within the device header. The pulse generator was then inserted into the pocket and secured to the fascia with O-Ethibond x1. The pocket was then closed in three layers of absorbable Vicryl suture. Steri-strips and a sterile occlusive dressing were placed over the incision site.
Thanks for your help in advance!!
Following oral and written informed consent, the patient was brought to the OR in a fasted, unsedated state. The presenting heart rhythm was atrial flutter (tcl 300 msec) with variable AV block. The patient was prepared and draped in the usual sterile fashion. The patient received cefazolin 2gram IVPB prior to incising. The patient received general anesthesia via LMA for sedation. Additionally, 2% lidocaine was infiltrated subcutaneously over the left infraclavicular region coincidental to the prior scar. Fluoroscopy was used to indentify anatomical landmarks and the location of the pacemaker pulse generator and pacemaker leads.
"An incision was made using a #10 scalpel coincidental to the prior incision. Blunt dissection and electrocautery were used to enter the pacemaker pocket. The silk suture securing the pulse generator to the floor of the pocket was identified, cut, and removed. The pacemaker pulse generator was removed from the pocket. The leads were disconnected from the pacemaker header and attached to the PSA. The right ventricular lead was found to have a high capture threshold (>8V at 1.5ms) and poor sensing. The right atrial lead had normal sensing and pacing impedance. The atrial flutter tachycardia cycle length was 300 msec. The right atrium was paced at 270 msec and the rhythm converted to sinus. The pacing threshold was then measured (see below).
The silk suture on the RV suture sleeve was cut and removed. A stiff (purple) stylet was inserted into the RV lead. The RV lead was freed by using gentle traction. The RV lead was withdrawn from the patient's body and set aside (It will be sent to Medtronic, Inc for analysis). A venogram was performed using 15cc of iodinated contrast dye x2 injections to demonstrate the location and patency of the left axillary/subclavian vein. Vascular access was obtained with a micropuncture kit using the modified Seldinger technique under fluoroscopic guidance x1. The micropuncture wire was upsized to a 0.35 J wire and a 7Fr sheath was inserted into the left axillary vein and flushed. A new active fix pacemaker lead was placed under fluoroscopic guidance and secured distally in the RV apical septum and proximally to the underlying fascia using O-Ethibond x2. High output pacing confirmed the absence of diaphragmatic capture. The right atrium was paced at 300msec through the PSA and the patient reverted to atrial flutter with variable AV block (presenting heart rhythm).
The pocket was then copiously irrigated with a saline-bacitracin solution. FloSeal was injected into the pocket. There was excellent hemostasis. The pacemaker pulse generator was then re-introduced to the surgical field and connected to the leads. Care was taken to ensure that the leads were securely fastened in the correct positions within the device header. The pulse generator was then inserted into the pocket and secured to the fascia with O-Ethibond x1. The pocket was then closed in three layers of absorbable Vicryl suture. Steri-strips and a sterile occlusive dressing were placed over the incision site.
Thanks for your help in advance!!