bennieyoung
Guru
attached is a report that I coded and I'm getting a claim error on it saying I'm missing the primary code. Can someone take a look for me? I coded 93623, 93620 and 33225.
Patient was brought to the EP lab in the fasting state. The right groin was prepped in the usual manner. Under ultrasound guidance and using a micropuncture the right femoral vein was accessed. A quadripolar catheter was guided to the RV. Pacing was performed down to 400, to 2020, 2020, 220, 220 milliseconds from both the RV apex and RVOT. Only 1 episode of nonsustained VT could be induced. No sustained VT or VF could be induced. This was repeated on and off isoproterenol with the same result.
Patient was then prepped for Bi V pacemaker implantation
The left pectoral area was prepped in the usual fashion. Using ultrasound guidance the left axillary vein was accessed with 3 separate sticks using micropuncture needle.
Using electrocautery and blunt dissection an incision was made medial to the DP groove. A pocket was then created.
The right atrial lead was placed through a 7 French sheath into the right atrium. The right ventricular lead was then placed through a 7 French sheath into the right ventricle. A Glidewire was then placed through the third access site and positioned in the heart.
An active fix right ventricular lead was used. It was guided to the right ventricular septum using the appropriate stylet. Under fluoroscopic guidance the helix was extended. Sensing and pacing characteristics were tested and found to be within normal. The lead was then tied down with 0 Ethibond and the suture sleeve. Sensing and pacing characteristics were tested again and found to be stable.
The multipurpose outer sheath was then used with the Glidewire. The coronary sinus was cannulated. A balloon occlusion venogram was performed revealing a posterolateral branch extending laterally. It was cannulated using the mailman coronary wire. An active fix CS lead was chosen and passed into the branch over the wire. Pacing and sensing characteristics were tested and found to be within normal. There was no phrenic stim at high output. The lead was then rotated clockwise several times deploying the fixation mechanism. A push and pull test was performed which demonstrated good adherence. The outer sheath was then slit using the appropriate tool. The CS lead was then tied down to the pectoralis muscle using 0 Ethibond and the provided suture sleeve.
Finally the right atrial lead was guided under fluoroscopic guidance using the appropriate stylet to the right atrial appendage. Sensing characteristics were found to be normal. The helix was deployed. The lead however dislodged.
It dislodged again after 2nd attempt. On the 3rd attempt a position slightly more lateral in the appendage was tried. Sensing characteristics for much better here. After helix deployment the lead did not dislodge. The lead was tied down to the pectoralis muscle using the provided suture sleeve.
Pocket was irrigated copiously with antibiotic solution.
The new pulse generator was attached to the leads using the provided wrench. It was then tucked into the pocket with the coiled pacing leads underneath it. The incision was closed using 2-0 and 3-0 and 4-0 Vicryl. Dermabond was placed on top of the incision. It was dressed with a light dressing. Fluoroscopy did not reveal a pneumothorax.
Conclusion:
Noninducible for VT VF despite aggressive programmed ventricular pacing protocol on and off isoproterenol
Successful left-sided CRT P implant
Chest x-ray ordered
Will admit overnight and consider cardioversion tomorrow for ongoing AFib
Patient was brought to the EP lab in the fasting state. The right groin was prepped in the usual manner. Under ultrasound guidance and using a micropuncture the right femoral vein was accessed. A quadripolar catheter was guided to the RV. Pacing was performed down to 400, to 2020, 2020, 220, 220 milliseconds from both the RV apex and RVOT. Only 1 episode of nonsustained VT could be induced. No sustained VT or VF could be induced. This was repeated on and off isoproterenol with the same result.
Patient was then prepped for Bi V pacemaker implantation
The left pectoral area was prepped in the usual fashion. Using ultrasound guidance the left axillary vein was accessed with 3 separate sticks using micropuncture needle.
Using electrocautery and blunt dissection an incision was made medial to the DP groove. A pocket was then created.
The right atrial lead was placed through a 7 French sheath into the right atrium. The right ventricular lead was then placed through a 7 French sheath into the right ventricle. A Glidewire was then placed through the third access site and positioned in the heart.
An active fix right ventricular lead was used. It was guided to the right ventricular septum using the appropriate stylet. Under fluoroscopic guidance the helix was extended. Sensing and pacing characteristics were tested and found to be within normal. The lead was then tied down with 0 Ethibond and the suture sleeve. Sensing and pacing characteristics were tested again and found to be stable.
The multipurpose outer sheath was then used with the Glidewire. The coronary sinus was cannulated. A balloon occlusion venogram was performed revealing a posterolateral branch extending laterally. It was cannulated using the mailman coronary wire. An active fix CS lead was chosen and passed into the branch over the wire. Pacing and sensing characteristics were tested and found to be within normal. There was no phrenic stim at high output. The lead was then rotated clockwise several times deploying the fixation mechanism. A push and pull test was performed which demonstrated good adherence. The outer sheath was then slit using the appropriate tool. The CS lead was then tied down to the pectoralis muscle using 0 Ethibond and the provided suture sleeve.
Finally the right atrial lead was guided under fluoroscopic guidance using the appropriate stylet to the right atrial appendage. Sensing characteristics were found to be normal. The helix was deployed. The lead however dislodged.
It dislodged again after 2nd attempt. On the 3rd attempt a position slightly more lateral in the appendage was tried. Sensing characteristics for much better here. After helix deployment the lead did not dislodge. The lead was tied down to the pectoralis muscle using the provided suture sleeve.
Pocket was irrigated copiously with antibiotic solution.
The new pulse generator was attached to the leads using the provided wrench. It was then tucked into the pocket with the coiled pacing leads underneath it. The incision was closed using 2-0 and 3-0 and 4-0 Vicryl. Dermabond was placed on top of the incision. It was dressed with a light dressing. Fluoroscopy did not reveal a pneumothorax.
Conclusion:
Noninducible for VT VF despite aggressive programmed ventricular pacing protocol on and off isoproterenol
Successful left-sided CRT P implant
Chest x-ray ordered
Will admit overnight and consider cardioversion tomorrow for ongoing AFib