jtuominen
Guru
Hi there-- having alot of trouble on this single ICD upgrade to Bi-Vent.
Wondering what others may code for this case-- I am inclined to the following codeset but I keep running into a device edit with the 33225 because there is no C1900 on the claim. The dictation reads like no bi-vent lead was placed because there was already one existing? Really confused! I think I may go back to the doc for clarification, or perhaps the wrong device code was applied, but wondering what you all thought about it. Here are the codes I am thinking of right now:
33240
33241
33225
33216
Devices
C1882
C1779
PROCEDURE:
1. Implantation of a new atrial lead.
2. Upgrade of a single-chamber ICD to a biventricular ICD.
INDICATION: Severe LV dysfunction with left bundle branch block.
HISTORY OF PRESENT ILLNESS: This is a delightful 42-year-old
gentleman with a history of severe ischemic cardiomyopathy who
recently had a single vessel bypass with the epicardial LV lead
implanted at that time. His LV function improved from 10-20%. He
does have a left bundle branch block greater than 120 milliseconds.
The patient is a New York Heart Class III and therefore would fit the
criteria for upgrade of his device to a biventricular ICD.
METHOD: After obtaining informed consent, the patient was prepped
and draped in the usual fashion. Intravenous antibiotics were given.
Conscious sedation was administered. 1% lidocaine was infiltrated
into the incision located below the mid left clavicle. An incision
was made with a #15 blade. The device was then removed from the
pocket and leads detached from the device. Under fluoroscopy, there
was one LV lead implanted epicardial lead that was bifurcated into
two different epicardial positions. Despite multiple attempts, I was
unable to locate the tip of this lead. Therefore, Dr. _______ came
in to assist the procedure. It was quite medial to the prior ICD
incision. An incision was made over this area and the lead was
identified. Appropriate sensings and threshold were obtained. There
was no diaphragmatic stimulation at high output pacing.
The left subclavian vein was then accessed using Seldinger technique.
A 6 French sheath was introduced into the subclavian vein. A lead
was then advanced to the heart and was fixed to the right atrial
appendage. Appropriate sensings and threshold were obtained. There
was no diaphragmatic stimulation on high output pacing. The sheath
was then peeled away. The lead was then secured onto pectoral muscle
using 0 Ethibond sutures.
The pocket was then irrigated with bacitracin solution. The leads
were then attached to the new device and placed in the pocket. Both
pockets were then closed with 2-0 and 4-0 Vicryl sutures.
Steri-Strips and OpSite dressing were then placed over the incision.
Intraoperative defibrillation testing was then performed. The
patient was transferred back to the care suite in stable condition.
Biventricular ICD generator: St. Jude Atlas V-366, 459065.
Replaced generator: St. Jude V-168, 370500 (11/23/2007).
LEAD INFORMATION:
1. RA, 1888TC-52 cm, BCG29495.
2. RV, 7020-65, ADK11026 (11/23/2007).
3. LV Medtronic 4968-60, LEN060250R (11/22/2008).
STIMULATION THRESHOLD:
1. RA: Measured at 2.5 mV, capturing at 0.75 volt at 0.5
milliseconds, 414 ohms.
2. RV: Measured greater than 12 mV, capturing at 1 volt at 0.5
milliseconds, 270 ohms.
3. LV: Measured greater than 12 mV, capturing at 1.5 volts at 0.5
milliseconds, 620 ohms.
Fluoroscopy time: 5.12 minutes.
COMPLICATIONS: None.
CONCLUSIONS:
1. Uneventful implantation of a new right atrial lead.
2. Uneventful upgrade of a single-chamber ICD to a biventricular
ICD.
3. Defibrillation threshold is at or below 25 joules, greater than
or equal to 10 joules safety margin.
Wondering what others may code for this case-- I am inclined to the following codeset but I keep running into a device edit with the 33225 because there is no C1900 on the claim. The dictation reads like no bi-vent lead was placed because there was already one existing? Really confused! I think I may go back to the doc for clarification, or perhaps the wrong device code was applied, but wondering what you all thought about it. Here are the codes I am thinking of right now:
33240
33241
33225
33216
Devices
C1882
C1779
PROCEDURE:
1. Implantation of a new atrial lead.
2. Upgrade of a single-chamber ICD to a biventricular ICD.
INDICATION: Severe LV dysfunction with left bundle branch block.
HISTORY OF PRESENT ILLNESS: This is a delightful 42-year-old
gentleman with a history of severe ischemic cardiomyopathy who
recently had a single vessel bypass with the epicardial LV lead
implanted at that time. His LV function improved from 10-20%. He
does have a left bundle branch block greater than 120 milliseconds.
The patient is a New York Heart Class III and therefore would fit the
criteria for upgrade of his device to a biventricular ICD.
METHOD: After obtaining informed consent, the patient was prepped
and draped in the usual fashion. Intravenous antibiotics were given.
Conscious sedation was administered. 1% lidocaine was infiltrated
into the incision located below the mid left clavicle. An incision
was made with a #15 blade. The device was then removed from the
pocket and leads detached from the device. Under fluoroscopy, there
was one LV lead implanted epicardial lead that was bifurcated into
two different epicardial positions. Despite multiple attempts, I was
unable to locate the tip of this lead. Therefore, Dr. _______ came
in to assist the procedure. It was quite medial to the prior ICD
incision. An incision was made over this area and the lead was
identified. Appropriate sensings and threshold were obtained. There
was no diaphragmatic stimulation at high output pacing.
The left subclavian vein was then accessed using Seldinger technique.
A 6 French sheath was introduced into the subclavian vein. A lead
was then advanced to the heart and was fixed to the right atrial
appendage. Appropriate sensings and threshold were obtained. There
was no diaphragmatic stimulation on high output pacing. The sheath
was then peeled away. The lead was then secured onto pectoral muscle
using 0 Ethibond sutures.
The pocket was then irrigated with bacitracin solution. The leads
were then attached to the new device and placed in the pocket. Both
pockets were then closed with 2-0 and 4-0 Vicryl sutures.
Steri-Strips and OpSite dressing were then placed over the incision.
Intraoperative defibrillation testing was then performed. The
patient was transferred back to the care suite in stable condition.
Biventricular ICD generator: St. Jude Atlas V-366, 459065.
Replaced generator: St. Jude V-168, 370500 (11/23/2007).
LEAD INFORMATION:
1. RA, 1888TC-52 cm, BCG29495.
2. RV, 7020-65, ADK11026 (11/23/2007).
3. LV Medtronic 4968-60, LEN060250R (11/22/2008).
STIMULATION THRESHOLD:
1. RA: Measured at 2.5 mV, capturing at 0.75 volt at 0.5
milliseconds, 414 ohms.
2. RV: Measured greater than 12 mV, capturing at 1 volt at 0.5
milliseconds, 270 ohms.
3. LV: Measured greater than 12 mV, capturing at 1.5 volts at 0.5
milliseconds, 620 ohms.
Fluoroscopy time: 5.12 minutes.
COMPLICATIONS: None.
CONCLUSIONS:
1. Uneventful implantation of a new right atrial lead.
2. Uneventful upgrade of a single-chamber ICD to a biventricular
ICD.
3. Defibrillation threshold is at or below 25 joules, greater than
or equal to 10 joules safety margin.