lcouto
Networker
I was thinking that this should be billed with CPT Code 33227 but not sure if I should bill for the wire cap... I am learning this as I go so any help would be appreciated... Thank you
Pre-procedure Diagnoses
1. Pacemaker lead failure, initial encounter
Post-procedure Diagnoses
1. Pacemaker lead failure, initial encounter
Procedures
1. PACEMAKER WIRES CAP
2. HC PACEMAKER VVIR SINGLE SYSTEM
BRIEF OPERATIVE NOTE
Pre-operative Diagnosis:
Pulse Generator at End of Life
Post-operative Diagnosis:
Same as above
Procedure Performed :
Pacemaker Generator change out
Anesthesia:
Moderate Conscious Sedation
Total IV Fluids & Blood loss;
Minimal blood loss
Drains:
None
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.
Lidocaine was used to infiltrate the skin and subcutaneous tissue overlying the left pectoralis muscle. Sharp incision was made in the skin. Utilizing a combination of sharp and blunt dissection, the old pulse generator was carefully dissected from its pocket in the prepectoral fascia.
The generator was removed and the leads were tested. The ventricular lead was capped and the atrial lead was capped. The atrial lead was no longer used as the patient was in permanent atrial fibrillation. The ventricular lead had rising thresholds in a patient who is pacemaker dependent. A segment of the atrial lead was cut during dissection and sent to pathology.
The patient was placed in Trendelenburg position. Percutaneous access was obtained in the subclavian vein utilizing the modified Seldinger technique. An .035 wire was advanced into the right atrium under fluoroscopic guidance. 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 .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 Paced, impedance 700 ohms, threshold was 0.6 volts, current 1.2 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 .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.
Pre-procedure Diagnoses
1. Pacemaker lead failure, initial encounter
Post-procedure Diagnoses
1. Pacemaker lead failure, initial encounter
Procedures
1. PACEMAKER WIRES CAP
2. HC PACEMAKER VVIR SINGLE SYSTEM
BRIEF OPERATIVE NOTE
Pre-operative Diagnosis:
Pulse Generator at End of Life
Post-operative Diagnosis:
Same as above
Procedure Performed :
Pacemaker Generator change out
Anesthesia:
Moderate Conscious Sedation
Total IV Fluids & Blood loss;
Minimal blood loss
Drains:
None
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.
Lidocaine was used to infiltrate the skin and subcutaneous tissue overlying the left pectoralis muscle. Sharp incision was made in the skin. Utilizing a combination of sharp and blunt dissection, the old pulse generator was carefully dissected from its pocket in the prepectoral fascia.
The generator was removed and the leads were tested. The ventricular lead was capped and the atrial lead was capped. The atrial lead was no longer used as the patient was in permanent atrial fibrillation. The ventricular lead had rising thresholds in a patient who is pacemaker dependent. A segment of the atrial lead was cut during dissection and sent to pathology.
The patient was placed in Trendelenburg position. Percutaneous access was obtained in the subclavian vein utilizing the modified Seldinger technique. An .035 wire was advanced into the right atrium under fluoroscopic guidance. 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 .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 Paced, impedance 700 ohms, threshold was 0.6 volts, current 1.2 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 .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.