Ask Dr. Z

Please do NOT include any actual patient medical records with your question. The patient had a biventricular implant AICD with removal of permanent pacemaker generator and right ventricular lead. The pacemaker and leads were carefully dissected out. Modifierd Seldinger techniques was then used to place two 9-Fr sheaths in the left subclavian vein. Therough these sheaths passed the endocardial leads. Right ventricular lead was positioned under fluoroscopic guidance in the right ventricular apex. Attempts were made to cannulate the coronary sinus with an Attain guide - cannulation was difficult. Using combination of catheters he was able to tie down the coronary sinus os. Once this was identified a deflectable-tipped catheter and a extra large curved Attain guide was used to cannulate. balloon tip catheter was placed in the coronary sinus. Coronary sinus venogram was performed in the LAO position. I was unable to pass the balloon catheter past the thebesian valve, but the coronary sinus venogram demostrated small lateral and anterolateral branch and a moderate size posterolateral branch. Initially, the left ventriculat lead was placed in the anterolateral branch, but after removal with Attain sheath there was evidence of dislodgement with elevated pacing threshold. Because of this, this was not felt to be a viable branch and the coronary sinus was recannulated and using Attain Select II catheter posterolateral branch was cannulated. The left ventricular lead was placed over a guidewire into the posterior lateral branch. After appropriate sensing and pacing parameters were confirmed, leads were secured. Once the leads were secured, the existing right ventricular lead was freed up and this was removed under fluoroscopic guidance with gentle traction w/o any resistance. The pacemaker was disconnected from the pacemaker leads and the pacemaker generator was removed from the pocket. The leads were connected to the defibrillator. Defibrillator was then placed in the packet. Defibrillation threshold testing was performed. I coded as follows: 33249, 33234, 33233, 93641 should I also charge for the fluroscopy as well as the venogram? Thanks, margie.clarkrn@yahoo.com