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Thread: Completely Stuck on this EP Study

  1. #1
    Join Date
    Apr 2007

    Default Completely Stuck on this EP Study

    AAPC: Back to School
    Hi there-- This case has been challenging many of the coders in our department. I am about ready to send it back for addendum, but I thought I would post it to see if anyone else can make sense of what exactly was performed here. So far I have


    And Im leaning towards

    I don't think it meets criteria for 93620 at all.

    Please help!

    1. EP study with induction of ventricular tachycardia.
    2. 3D intracardiac mapping.
    3. Ablation of the left ventricular tachycardia.

    INDICATION FOR PROCEDURE: Patient is a 69-year-old white male
    with a history of coronary artery disease and severe LV dysfunction.
    He had a previous VT ablation which reduced the number of ICD shocks.
    However, over the recent few months, the patient started to have
    increasing frequency of ICD shocks from once a week to almost daily
    in the last few days. He has been on antiarrhythmic drug therapy
    without success. After the risks and benefits of the procedure were
    explained the patient consented for a repeat ablation.

    PROCEDURE AND RESULTS: After the written informed consent was
    obtained, the patient was transported to CV Lab 4 in the fasting
    state. The procedure was performed under local anesthesia and
    sterile conditions. IV Versed and fentanyl were used for conscious
    sedation. By using the Seldinger technique, a 6 French quadripolar
    catheter was inserted through the right femoral vein and positioned
    into the RV apex for induction of VT. The ESI balloon mapping
    catheter was inserted through the left femoral artery and positioned
    into the left ventricle. The ablation catheter was an 8 mm EPT that
    was inserted through the right femoral artery and positioned into the
    The patient received heparinization after the access of the
    femoral artery.

    He was in sinus rhythm with first degree AV block and left bundle
    branch block at the baseline. There were frequent PVCs of single
    morphology. The PVC was mapped to the upper left ventricular septum.

    The patient has a very large left ventricle which was beyond the
    mapping range of the balloon mapping catheter. The mapping and
    ablation was guided by the Array mapping system.
    The left ventricle
    geometry was collected by using the ablation catheter and the balloon
    mapping catheter. It was observed that extensive scar was present
    over the left ventricle. The only viable myocardial area was the
    anterior lateral basal LV where the epicardial left ventricular
    pacing lead was placed.

    The patient had multiple very wide QRS VTs with different rates in
    QRS morphologies. The VTs were induced by triple ventricular
    extrastimuli and on one occasion by catheter manipulation. None of
    the VT was pace terminable. The conventional mapping and balloon
    mapping both indicated origin of the VTs from the apical septal area
    near the border of the scar.

    Due to the unstable status of the VT the ablation was performed along
    the border of the scar.
    A linear lesion was created from the apical
    septum up to the anterior septum just below the level of the His
    bundle. None of the ablations were applied in the healthy
    myocardium. Furthermore, the ablation was extended in the
    anterolateral apical toward the apical septum.
    The PVC at baseline
    disappeared during the ablation procedure. Due to the close location
    of those PVCs to the His bundle region no ablation was applied to the
    basal left ventricular septum.

    After the ablation of the left ventricular anterior septum, the
    patient had continued induction of VT of at least two types.
    None of
    them was terminable by pacing but the rate seemed to be slowed down
    to about 170 beats per minute.

    Due to the extensive scar tissue, low ejection fraction and the long
    procedure time it was decided to abort the ablation for concern of

    At the end of the procedure, the catheters and sheaths were removed
    and local pressure was applied to the puncture sites. The pacing
    rate was increased to 80 beats per minute in order to suppress the
    PVC and hopefully will reduce the incidence of VT empirically.
    Otherwise, there was no complication.

    For the short time being, sotalol will be continued at the same
    dosage. Mexiletine is discontinued because of the complaint of severe
    stomach upset. If he improves clinically with ventricular arrhythmia
    the dosage of sotalol may be reduced.

  2. #2



    I agree with the codes you have selected: 93600 93603 93652 & 93613. The doctor could have added modifier 22 to 93652 if he mentioned he accessed the left ventricle through transseptal puncture, assuming that is how he entered the left ventricle.

    good luck, this one was alittle tricky.


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