Case-of-the-Month Archives

Each month ZHealth Publishing will identify a particularly complex and/or relevant interventional radiology or cardiology coding case to profile and analyze for ZHealth Online members:

Case-of-the-Month: October 2008

PROCEDURE PERFORMED

1. Left subclavian venogram.
2. Temporary transvenous pacemaker insertion.
3. Arterial line placement for close hemodynamic monitoring.
4. Implantation of a new ICD lead.
5. Implantation of a new left ventricular lead.
6. Explantation of the dual chamber permanent pacemaker.
7. Pocket revision.
8. Implantation of new dual chamber biventricular defibrillator generator.
9. Capping the existing ventricular lead.
10. DFT testing.

INDICATION FOR PROCEDURE:
Patient with left bundle branch block predominantly paced rhythm without any underlying rhythm of his own.  He had permanent pacemaker implantation for symptomatic AV block in 1997 with generator change out in 2007.  He is in class IIIB congestive heart failure as per New York Heart Association.  Patient is undergoing this procedure due to declining activity, class III congestive heart failure, left bundle branch block with QRS duration greater than 180 milliseconds, ischemic cardiomyopathy with low ejection fraction.

PROCEDURE:
Since the patient had this pacemaker for a long time it was decided to do a venogram to check for the patency of the left subclavian vein. The arm was not swollen and he had no complaints pertinent to the arm.  The venogram showed patent axillary as well as left subclavian vein.

The right groin area was prepped and draped in the usual sterile fashion.  Patient did not have any underlying rhythm of his own (complete heart block) so it was decided that he needed a temporary pacemaker insertion as a backup.  Patient’s ejection fraction is 10% and it was felt that he needed close hemodynamic monitoring through the procedure.  1% lidocaine was administered for local anesthesia and access was obtained to the right femoral vein via 18 gauge Cook needle.  7 French dilator and sheath were inserted by modified Seldinger technique in the right femoral vein.  The dilator and wire were removed.  A bipolar temporary transvenous pacemaker lead was inserted through the sheath and under fluoroscopic guidance this was advanced to the right ventricular apex.  Capture thresholds were evaluated and judged to be adequate.  Dressing was applied and Bioclusive was applied to secure the lead as well as the sheath to the underlying skin.

Access was then obtained to the right femoral artery via an 18 gauge Cook needle.  Guidewire was introduced into the region of the right femoral artery and short 4 French sheath was inserted modified Seldinger technique into the right femoral artery.  The dilator and wire were removed and that was hooked up to a tubing system for close hemodynamic monitoring.

Attention was then directed to the left subclavian area.  The left shoulder area was prepped and draped in the usual sterile fashion.  2% lidocaine was administered for local anesthesia.  An incision was made with a #5 blade over the previous scar which was extended more medially.  The wound was deepened by using blade as well as electrocautery.  The capsule of the device was reached and incised.  The suture material holding the device was severed and the device was retrieved from the pocket.  The leads were carefully separated from the underlying tissue by using electrocautery.

Access was obtained to the left axillary vein via an 18 gauge Cook needle x 2.  I was trying to manipulate the guidewire however it was not able to be advanced beyond the RA/SVC junction, at which time the guidewire was exchanged for a glidewire and I was able to manipulate the glidewire all the way into the inferior vena cava.  Over the glidewire, a 9 French access sheath was inserted into the left subclavian vein.  The dilator and the wire were removed.  7 French Attain guide catheter was inserted over decapolar pacing catheter into the region of the right atrium.  The decapolar catheter was then advanced into the coronary sinus under fluoroscopic guidance.  The guide catheter was then advanced over the decapolar catheter into the coronary sinus.  The pacing catheter was then removed and contrast material was injected.  This showed that the guide catheter was in the middle cardiac vein. The vein was small and irregular requiring venoplasty with a 4mm balloon. Post venoplasty the lumen appeared large enough to accomadate the LV lead.  At that point, the guide catheter was retrieved back and I used a deflectable decapolar catheter to be advanced into the main coronary sinus.  Over the decapolar catheter the guide catheter was then advanced into the main coronary sinus into the higher portion.  The decapolar catheter was then removed and contrast material was injected which was filmed in both the AP as well as LAO projections.  This showed a nice posterolateral branch coming out of the coronary sinus.  I used a 6 French Bipolar Medtronic lead to place this into the posterolateral branch.  Over one of the sub branches he did have higher capture thresholds and also diaphragmatic pacing, so I advanced the lead farther out where he had reasonable threshold without any diaphragmatic pacing at 10 volts.

The other guidewire was exchanged for a glidewire again through a 4 French sheath.  A long 9 French hemostasis valve sheath over a dilator was advanced into the right atrium.  The dilator and the wire were removed.  The ICD lead was advanced through the sheath to the region of the right atrium. The ICD lead was then positioned in the right ventricular apex under fluoroscopic guidance.  The tear-away sheath was then slit and taken away.  Active fixation screw was then advanced to secure the lead in place.  Electrograms were not able to be judged because patient is completely dependent on the pacemaker.  The atrial lead was then disconnected from the pacemaker pulse generator.  The atrial lead was checked for both sensing and capture thresholds.  The ventricular lead was then disconnected from the pacemaker generator and it was capped using 2-0 silk.  All three lead were checked again.

In the atrium in the bipolar mode, P waves measured 1.5 millivolts.  Capture threshold in the atrial lead was 1.5 volts at 0.5 milliseconds with a current threshold of 3.6 mA.  The atrial lead impedance was 461 ohms.

In the left ventricle, in the bipolar mode, ventricular lead impedance was 706 ohms in the coronary sinus lead.  Capture threshold in the lead was 2.1 volts at 0.4 milliseconds.

Redundancy of the leads was carefully assessed and the leads were secured to the superficial pectoralis fascia using 2-0 silk on the tie-down sleeves.  All the leads were retested at 10 volts which did not show diaphragmatic pacing.

The pocket was expanded to accommodate the capped existing ventricular lead and the two new leads and the bigger generator.  Pocket was irrigated with antibiotic solution.  The leads were connected to the pulse generator.  The pulse generator and excess leads were placed back in the pocket as well as the capped ventricular lead.  The device was tied down to the superficial pectoralis fascia using 2-0 silk on the tie down hole.

DFT testing was then performed. Ventricular fibrillation was induced with T-shock and the device was allowed to detect VF and give a biphasic shock.  The delivered energy was 14.1 joules, impedance was 13 ohms, charge time was 2.48 seconds and outcome was successful.

Having met the DFT criteria the wound was closed in layers.  Subcutaneous tissue was reapposed using running 2-0 Vicryl S-stitch in two layers and the skin was reapposed using running 4-0 Vicryl subcuticular stitch.  Steri-strips, Betadine, and sterile dressings were applied to the wound.  The patient tolerated the procedure well.  No complications were noted during the procedure.  Estimated blood loss was around 10 mL.

Capped ventricular lead manufacturer is Medtronic, model #5034-58 cm, serial #LDF056594V, date of implant 06/11/1997.

Atrial lead manufacturer is Medtronic, model #5068-52 cm, serial #LDJ009346V, date of implant 06/11/1997.

Explanted pacemaker generator manufacturer is Medtronic, model #E2DR01, serial #PNB43877H, date of implant 04/25/2005.

ICD lead manufacturer is Medtronic, model #6947-58 cm, serial #TDG252485V.

LV lead manufacturer is Medtronic, model #4194-78 cm, serial #LFG113065V.

Pulse generator manufacturer is Medtronic, model #C154DWK, serial # PVR468081H, brand is Concerto.

Patient recovered from anesthesiology nicely and was transferred to recovery room in hemodynamically stable condition.  The temperature as well as pacemaker lead were taken out from the heart under fluoroscopy and both arterial sheath as well as venous sheaths were removed before the patient left the room.  Hemostasis was achieved with manual pressure.

CASE CODES

33210-59 – Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure)
33225 – Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (including upgrade to dual chamber system) (List separately in addition to code for primary procedure)
33233 – Removal of permanent pacemaker pulse generator
33249 – Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator
71090 – Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation
93641 – Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement; with testing of single or dual chamber pacing cardioverter-defibrillator pulse generator

CASE CODE DISCUSSION

The patient presented with a dual chamber pacemaker, which was upgraded to a bi-ventricular intracardiac defibrillator (ICD).  A new right ventricular lead was also placed.  There were several activities involved.  Some are separately reported and some are not.

The first activity was an extremity venogram to check patency of the vein for lead placement.  This imaging is inherent in the lead placement and not reported separately.   If the patient would have had symptomology to indicate a stenosis, (such as a swollen arm)  venography may be reported separately. Per the Heart Rhythm Society, code 75820 is not used for venography performed to determine vein patency (Coding Guide for Heart Rhythm Procedures and Services, page 46).

Next a temporary pacemaker was placed.  The patient is pacemaker-dependent so placement of the temporary pacemaker is reported separately with code 33210.  Code 33210 is a column 2 edit with subsequently assigned code 33249, so a -59 modifier must be appended in this scenario.

A monitoring catheter was placed.  Monitoring is not reported separately as it is inherent in the procedure performed.

The existing pacemaker is removed and is reported separately with CPT code 33233.  This code includes all activities to remove the pacemaker.

A left ventricular (LV) lead was placed.  Contrast was injected in the coronary sinus and venography performed to provide guidance for the lead placement.  This imaging is included in the LV lead placement and not reported separately.  The venoplasty is also a bundled component of the LV lead placement.  Stretching the vein, or even treating the irregularity of the vein with a balloon is considered part of the preparation  sometimes necessary for the  procedure to place the LV lead.  When the LV lead is placed at the time a new generator is placed it is reported with code 33225.  Had the existing generator been re-used instead of replaced, code 33224 would be reported instead.

An ICD lead was placed in the right ventricle.  This would normally be reported with code 33216, Insertion of a transvenous electrode; single chamber (one electrode) permanent pacemaker or single chamber pacing cardioverter-defibrillator, but since it is performed at the same time as generator replacement, the two replacements are combined.   The replacement of the generator and a lead are bundled and reported with code 33249, replacement of an entire system.  A comprehensive code is always reported when it includes components that have individual codes.  Code 33249 is reported instead of the two components (33216 and 33240, Insertion of single or dual chamber pacing cardioverter-defibrillator pulse generator).

The old right ventricular lead was capped.  Capping of a lead is not reported separately.  Only if a lead is removed is it reported.

The pocket was enlarged to accommodate a larger generator.  This is included in the generator change and is not reported separately as a pocket revision.

Fluoroscopic guidance is well documented and reported with code 71090.

Electrophysiology testing of the defibrillator (DFT) was performed.  This procedure is reported separately with code 93641.

The hospital may also report recovery room services for the time the patient was in the designated recovery room.

Device codes are required for hospital billing.  The LV lead is reported with code C1900 and the ICD is reported with code C1882.

CPT codes Copyright © 2008 American Medical Association. All Rights Reserved.

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