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Thread: EP help

  1. #1

    Default EP help

    AAPC: Back to School
    Could someone please help with the diagnostic EP portion of this report? If you could also let me know the rationale, that would be great!!

    Informed consent was obtained. The patient was brought to the EP laboratory in a
    fasting state. The groin area was then prepped and draped in the usual sterile
    fashion. 1% Xylocaine was used for local anesthetic. Modified Seldinger technique
    was used to access the bilateral femoral veins to allow for insertion of 3 venous
    sheaths. A deflectable Decapolar catheter was then introduced and was used to
    cannulate the coronary sinus. According to the coronary sinus activities activation
    mapping, it appeared to be right-sided atrial tachycardia. The mapping/ablating
    catheter was then introduced into the right atrium using a supporting DAIG SL2
    curved sheath. The catheter was a Biosense, thermo-cooled catheter. Mapping was
    then performed. According to the mapping data, it appeared to be counterclockwise
    atrial flutter rotation. Pacing at the right atrial isthmus region indicated that
    it was within the atrial flutter circuit. Ablation was then performed. Several
    applications were delivered along the isthmus. During the process of creating an
    ablation line along the isthmus, it was noted that the activation of the atrial
    tachycardia/flutter changed with the earliest activation appearing to be equal in
    all the CS leads. After completion of the isthmus line, mapping was then
    reperformed. Now the activation sequence has changed and it appeared to be coming
    from the left atrium.

    An intracardiac echocardiogram catheter was then introduced into the right atrium.
    It was a Biosense bowel sounds catheter. Using the Cartosound 3-D mapping system,
    the left atrial shell was then reconstructed. Subsequent, transseptal
    catheterization was then performed using a Preface sheath under the guidance of ICE,
    hemodynamics and fluoroscopy without any complications. Heparin bolus and heparin
    drip were then given and adjusted during the procedure to maintain ACT about 250-300
    seconds range. The ablating catheter was then introduced into the left atrium and
    detailed mapping was then performed.

    Using entrainment mapping coupled with activation mapping data, there appeared to be
    focal atrial tachycardia located at the mitral annulus region near the base of the
    left atrial appendage. Several applications were delivered at this site, along the
    annulus, and toward the base of the left atrial appendage, with power titrated up to
    40 watts. Despite good mapping data, the atrial tachycardia persisted. After about
    40 applications, remapping was then performed. Using activation mapping data
    coupled to entrainment mapping data, it appeared to be reentrant circuits around the
    mitral annulus. It should be noted earlier that macro reentrant circuits along the
    left atrial roof was quickly ruled out by activation mapping data.

    The mitral isthmus was then ablated. The catheter was initially brought toward the
    ventricular side of the mitral annulus and clockwise rotation toward the left
    inferior pulmonary vein. The power was titrated up to 40 watts and at this
    location, spot application was delivered at each site lasted for about 30 seconds
    each. Despite establishment of a good mitral isthmus line, the atrial tachycardia
    persisted. There appeared to be good atrial signal in the coronary sinus region.
    Therefore, the patient was cardioverted to sinus rhythm with 100 joules.
    Differential pacing was performed indicating there was still conduction across the
    mitral isthmus. The ablating catheter was then withdrawn from the left atrium and
    introduced into the coronary sinus where good atrial signal was obtained at the mid
    coronary sinus region corresponding to the mitral isthmus ablation line.
    Applications were delivered at this site with power titrated up to 20 watts.
    Proximal coronary sinus pacing was performed during the application to document
    local conduction block. About 10 applications were delivered within the coronary
    sinus. Subsequently, the ablating catheter was then reintroduced into the left
    atrium and differential coronary sinus pacing was then performed. There was still
    conduction across the mitral isthmus and therefore several more application were
    delivered along the mitral isthmus with power titrated up to 40 watts. Coronary
    sinus pacing was performed during RF applications to document conduction block.
    Eventually, after several applications, we were able to document local conduction
    block. Differential pacing was then performed with evidence of conduction block
    across the mitral isthmus region with the conduction time of about 110 milliseconds
    as opposed to 20 milliseconds prior to the mitral isthmus ablation. A total of 115
    RF applications were delivered during procedure with a total application time of
    3945 seconds. After achievement of mitral isthmus block, the intracardiac
    echocardiogram was then performed to look for pericardial effusion. There was no
    evidence of pericardial fluid present. At this point, all the catheters and sheaths
    were then removed once the ACT was less than 180 seconds. The patient tolerated the
    procedure well and there were no apparent complications.

  2. #2


    The dictation style is not what I'm used to, but I'll take a crack at it. The codes I was able to divine were:


    Resist the temptation to code 92960 for the cardioversion in this instance since it appears to be aimed at the arrhythmia that was induced during the procedure.

    Also, the mention of the "Biosense bowel sounds catheter" has to be one of the most amusing transcription errors I've seen in a while.

    Hope this helps.

  3. #3


    Thanks for your help! Why is 93620 able to be billed? It is my understanding that RA, RV pacing/recording and His bundle recording needs to be done in order to bill a comprehensive study. Is that not correct?

  4. #4


    I read your report, but I wouldn't bill the 93620 based off this report only because the actual pacing of each area and recording isn't mentioned. My Dr's state those specific areas as paced and recorded in their reports. If they don't mention it, I send it back to be reviewed and have an addendum added if needed before its billed out.


  5. #5


    Thanks....thats what I was thinking with this report but wasn't quite sure. This can be very confusing. Thanks for your help!!

  6. #6


    Good Luck and you are welcome!

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