bennieyoung
Guru
I have an auditor that is questioning my coding on a patient that had an ablation done and then a single chamber PM inserted. The ablation was done for atrial fib and patient developed complete heart block and pacemaker inserted. My auditor doesn't think I should use the complete heart block diagnosis as that wasn't the reason for the ablation and was created by the ablation. My coding was this: 93650 with I48.21 and 33207-KX with I44.2 I will attach the note and I'm hoping someone takes a look and tells me their take on this.
Procedures:
Left upper extremity venogram
Monitored anesthesia care
Fluoroscopy
Pacemaker implantation with left bundle branch conduction system lead
RF ablation cardiac
3D CARTO mapping
PerClose venous closure
Reprogramming Pacemaker
PreProcedure Dx: Permanent atrial fibrillation
PostProcedure Dx: Permanent atrial fibrillation, complete AV block due to AV node ablation
Clinical Hx and indication: Permanent atrial fibrillation that failed medical management.
Procedure: The patient was prepped and draped in sterile fashion. A venogram using 5cc of contrast and 5cc of NS demonstrated patency of the left upper extremity venous system. The left chest was prepped and draped in sterile fashion. A 3 cm incision was made over the location of the axillary vein. Cautery and blunt dissection was used to form a subcutaneous pocket. A micropuncture needle then sheath were used to obtain access into the axillary vein over the rib to avoid pneumothorax. A 7Fr sheath was advanced over the wire.
A C315-His sheath was advanced over a GlideWire through the 7Fr sheath into the right ventricle. A location on the septum was mapped. With pacing before fixation, there was a "W" pattern in lead V1. The lead was manually screwed into place under fluoro as LAO into the septum. The stim-V5 interval was 61 ms and threshold was good. QRS width was 100ms. The sheath was slit and lead secured. The lead remained stable. The 7Fr sheath was peeled and removed. The lead was secured at its entrance into the muscle with 0-Silk x2.
The pocket was then irrigated with antibiotic solution. The lead was connected to the device and the device and lead placed in the pocket. The pocket was then closed with three layers: continuous 0-Vicryl subcutaneous, continuous 3-0 Vicryl, and continuous 4-0 Vicryl subcuticular. There was a final skin closure with steri-strips. A sterile dressing was placed. There was no immediate complication.
Device Information:
Generator Medtronic W1SR01 SN RNA023586G
RV/Left bundle pacing lead 383069 SN LFF591713V
Lead testing:
RV/Left bundle pacing lead R wave 6mV, imp 950 ohms, threshold 0,5V@0.4ms
The pacemaker was programmed as VVI 30 for the AV node ablation.
Sheaths:
RFV 8Fr sheath for Smart Touch irrigated mapping and ablation catheter
Mapping and ablation
The His was located with the ablation catheter and marked on the CARTO system. RF lesions of 35W were placed for up to one minute but halted if no AV block occurred. After a series of lesions were placed, complete AV block developed. Ventricular pacing occurred. This persisted for a 30 minute testing period.
The device was interrogated and found normal function of device and leads.
The device was reprogrammed: VVIR 90-120
After this, the sheath was pulled. PerClose was used. Pressure was held for 10 minutes. The pt tolerated the procedure well with no immediate complication.
Conclusion Successful pacemaker placement with AV node ablation. Lower rate 90bpm for two weeks, then 80bpm for two weeks, then 70bpm long term.
Procedures:
Left upper extremity venogram
Monitored anesthesia care
Fluoroscopy
Pacemaker implantation with left bundle branch conduction system lead
RF ablation cardiac
3D CARTO mapping
PerClose venous closure
Reprogramming Pacemaker
PreProcedure Dx: Permanent atrial fibrillation
PostProcedure Dx: Permanent atrial fibrillation, complete AV block due to AV node ablation
Clinical Hx and indication: Permanent atrial fibrillation that failed medical management.
Procedure: The patient was prepped and draped in sterile fashion. A venogram using 5cc of contrast and 5cc of NS demonstrated patency of the left upper extremity venous system. The left chest was prepped and draped in sterile fashion. A 3 cm incision was made over the location of the axillary vein. Cautery and blunt dissection was used to form a subcutaneous pocket. A micropuncture needle then sheath were used to obtain access into the axillary vein over the rib to avoid pneumothorax. A 7Fr sheath was advanced over the wire.
A C315-His sheath was advanced over a GlideWire through the 7Fr sheath into the right ventricle. A location on the septum was mapped. With pacing before fixation, there was a "W" pattern in lead V1. The lead was manually screwed into place under fluoro as LAO into the septum. The stim-V5 interval was 61 ms and threshold was good. QRS width was 100ms. The sheath was slit and lead secured. The lead remained stable. The 7Fr sheath was peeled and removed. The lead was secured at its entrance into the muscle with 0-Silk x2.
The pocket was then irrigated with antibiotic solution. The lead was connected to the device and the device and lead placed in the pocket. The pocket was then closed with three layers: continuous 0-Vicryl subcutaneous, continuous 3-0 Vicryl, and continuous 4-0 Vicryl subcuticular. There was a final skin closure with steri-strips. A sterile dressing was placed. There was no immediate complication.
Device Information:
Generator Medtronic W1SR01 SN RNA023586G
RV/Left bundle pacing lead 383069 SN LFF591713V
Lead testing:
RV/Left bundle pacing lead R wave 6mV, imp 950 ohms, threshold 0,5V@0.4ms
The pacemaker was programmed as VVI 30 for the AV node ablation.
Sheaths:
RFV 8Fr sheath for Smart Touch irrigated mapping and ablation catheter
Mapping and ablation
The His was located with the ablation catheter and marked on the CARTO system. RF lesions of 35W were placed for up to one minute but halted if no AV block occurred. After a series of lesions were placed, complete AV block developed. Ventricular pacing occurred. This persisted for a 30 minute testing period.
The device was interrogated and found normal function of device and leads.
The device was reprogrammed: VVIR 90-120
After this, the sheath was pulled. PerClose was used. Pressure was held for 10 minutes. The pt tolerated the procedure well with no immediate complication.
Conclusion Successful pacemaker placement with AV node ablation. Lower rate 90bpm for two weeks, then 80bpm for two weeks, then 70bpm long term.
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