Need Help with Coding Please

lcouto

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I think that I may have figured this out but not feeling positive about it... I think that this would be billed as a 33207 and 33233... Can I please have some input....

Pre-procedure Diagnoses
1. Pacemaker lead failure, initial encounter
2. Subclavian vein obstruction, left


Procedures
1. PACEMAKER SC NEW
2. PACEMAKER WIRES CAP

BRIEF OPERATIVE NOTE


Pre-operative Diagnosis:
Pacemaker lead failure

Post-operative Diagnosis:
Same as above

Procedure Performed :
Implantation of Permanent Pacemaker


Anesthesia:
Moderate Conscious Sedation

Total IV Fluids & Blood loss;
Minimal blood loss

Drains:
None

Specimens Removed:
Medtronic VEDR01

Implants and Procedure Description:
After informed consent was obtained, the patient was transported in a nonsedated condition to the cardiac catheterization suite. The patient was given moderate conscious sedation. The patient was prepped and draped in a sterile fashion and a "timeout" was taken.

ACCESS and POCKET FORMATION:
Lidocaine was used to infiltrate the skin and subcutaneous tissue overlying the left pectoralis muscle. Using a combination of blunt and sharp dissection, the pacemaker was removed from the left prepectoral pocket. The device was disconnected and the leads tested. We confirmed high to high impedance and thresholds of the left ventricular lead. Under fluoroscopic guidance percutaneous access was obtained in the left axillary vein. I then attempted to pass a wire through the subclavian vein. This was occluded. I took a venogram confirming the occlusion. I then tried to cross through the total occlusion with a Glidewire but was unsuccessful. The decision was made to abandon the left prepectoral pocket and place a new generator and system via the right subclavian approach. The atrial and ventricular leads were capped and secured to the pectoralis muscle. Pocket was copiously irrigated and then closed in layers with 3-0 Vicryl suture. The skin was closed with 4-0 Vicryl suture and Dermabond adhesive.


The patient was placed in Trendelenburg position. Percutaneous access was obtained in the right subclavian vein utilizing the modified Seldinger technique. An .035 wire was advanced into the right atrium under fluoroscopic guidance. Sharp incision was made in the skin. Utilizing a combination of sharp and blunt dissection, a pocket was formed in the prepectoral fascia.
VENTRICULAR LEAD:
Over the .035 wire, an 8 French peel-away sheath was advanced. The dilator was removed, and a second .035 wire was placed through the sheath. The sheath was removed and then reintroduced over one of the .035 wires. The wire and dilator were exchanged then for the ventricular pacing lead. The lead was an active fixation lead (Medtronic 5076-52 ) Utilizing curved and straight stylettes, the lead was positioned and secured in the right ventricular apex. It was tested and found to have R waves of 0 mV, impedance 679 ohms, threshold was 0.5 volts, current 0.8 milliamps. Adequate slack was placed in the lead under fluoroscopic guidance. The lead was tested with output of 10 V and did not stimulate the diaphragm.

CLOSURE:
The leads were then secured to the pectoralis muscle with non-resorbable suture. I then attached the pulse generator (Medtronic ADSR01 ) The leads and pulse generator were incorporated in the pocket. The pocket was copiously irrigated with antibiotic solution. The subcutaneous fascia was closed with interrupted 3-0 Vicryl suture. The skin layer was closed with a running subcuticular 4-0 Vicryl suture and Surgiseal adhesive. Final fluoroscopy demonstrated adequate slack in the leads. The wound was dressed in a sterile fashion.
 
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