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Infected pacemaker with large vegetation

  1. Default Infected pacemaker with large vegetation
    Medical Coding Books
    I would appreciate some advice with coding this surgery:

    "Explantation of a permanent pacemaker battery and leads under cardiopulmonary bypass. Exploration of aortic valve and mitral valve under direct exposure. Ligation of left atrial appendage."

    This was done through a median sternotomy and on cardiopulmonary bypass. The infected pacemaker battery & leads were removed, then both mitral and aortic valves were exposed and carefully examined. There was no vegetation or evidence of infection.

    I can give more information and/or operative report if needed.

    What codes would be appropriate to bill for the exploration of the valves with no repair being done?

  2. #2
    Richardson, TX
    Hi there,

    I code the AVRs and MVRs all the time but I have never had this scenario. I looked at some different codes and I believe you may be able to use 35761; Exploration (not followed by surgical repair), with or without lysis of artery - other vessels. Check to see if it bundles to anything else he is doing but it may work.

    If anyone thinks that is wrong please let me know. Or if anyone has a better suggestion that is welcomed too.

    Hope I helped maybe a little. You could always ask your physician if he agrees or what code he suggests matches what the work he did.
    Julie Graham, BA, CPC, CCC

  3. Default
    I believe 35761 is more for exploration of arteries and veins, not the chambers/valves of the heart.

    I would consider billing 33315. Check CCI for bundling.

    Lisi, CPC

  4. Default
    Thanks for the help. I really appreciate it.

    Cathy, CPC

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