# Advice please-EP study



## Jess1125 (Sep 7, 2012)

Hi,

I'm reading my first ever EP study and unfortunately, I don't feel I can pick out the parts from this note. Does the provider need to do better documentation? Or is his documentation okay and I just need to learn what in this report is telling me these codes are supported? Provider billed 93620-26, 93621-26, and 93623-26. 

1) I'm not seeing all the components of 93620-26. I see the catheter being put in the HIS position.  

2) Provider states in report that a catheter was used for left atrial pacing and recording but I guess I don't know where that is supported in the report. Anybody want to tell me what I'm looking for in this report to tell me the left atrial pacing and recording was done? 

3) I see the patient being given Isuprel on various dosages so I feel the 93623-26 is supported. 

Advice please. I'm sure I'll get better the more EP studies he does but I'm lost on this first one and need guidance. I'll paste in the pertinent part of the note! 

DESCRIPTION OF PROCEDURE:  The indication, risks, benefits, alternatives, and details of the procedure were discussed with the patient, and she provided informed written consent.  The patient was brought to the electrophysiology laboratory, where she was prepped and draped in the usual sterile fashion.


Lidocaine was used to anesthetize the right inguinal region.  Using an introducer needle, right femoral venous access was obtained, and 3 sheaths were placed.  Through an 8-French locking sheath, a Duo-Deca deflectable EP catheter was advanced to the coronary sinus under fluoroscopic guidance.  This was used for left atrial pacing and recording.  Similarly, deflectable quads were advanced through 7-French and 8-French sheaths to the RVOT and His positions, respectively.


The presenting rhythm was sinus rhythm with a baseline cycle length of 1220 milliseconds.  The PR was 100 milliseconds, QRS duration of 87, and Q-T of 333.  The AH was 47 milliseconds with an HV of 62.


Programmed stimulation was then performed in the ventricle and the atrium.  There was no clear VA conduction noted at baseline.  The AV Wenckebach cycle length was 370 milliseconds.  Extrastimulus pacing was then performed from the atrium.  The AERP was 600/250 with AV nodal AERP less than or equal to 600/250.  There was no evidence for an A2-H2 jump.  Decremental extrastimulus pacing was then repeated with a drivetrain of 400 milliseconds.  The AV nodal ERP was 400/220.  


The patient was then started on Isuprel at 1 mcg per minute.  The AV Wenckebach cycle length was 350 milliseconds on 1 of Isuprel.  This was then increased to 2 mcg per minute.  


With AV Wenckebach pacing on 2 mcg of Isuprel, the patient was noted to go into monomorphic VT with a right bundle, left superior axis, R-wave transition at V4, with a tachycardia cycle length of 350 msec.  The VT was self-terminated.  The patient felt symptoms similar to her palpitations during the VT.  She did not become hemodynamically unstable prior to the spontaneous termination.


Given the patient's easily inducible monomorphic VT with no inducible SVT, the decision was made to pursue pharmacologic treatment of the patient's ventricular tachycardia.


At the conclusion of the procedure, catheters were removed under fluoroscopic guidance. Sheaths were pulled and hemostasis achieved with manual pressure. The patient was then transferred to the recovery area in stable condition.


The patient's device was reinterrogated, and the tachycardia parameters were adjusted based on the findings of today's EP study.  The VT zone was decreased to 165 beats per minute, and a monitor zone was also added.


Jessica CPC, CCC


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## Robbin109 (Sep 8, 2012)

I highlighted the important parts...hope this helps.


DESCRIPTION OF PROCEDURE: The indication, risks, benefits, alternatives, and details of the procedure were discussed with the patient, and she provided informed written consent. The patient was brought to the electrophysiology laboratory, where she was prepped and draped in the usual sterile fashion.


Lidocaine was used to anesthetize the right inguinal region. Using an introducer needle, right femoral venous access was obtained, and 3 sheaths were placed. Through an 8-French locking sheath, a Duo-Deca deflectable *EP catheter was advanced to the coronary sinus under fluoroscopic guidance. This was used for left atrial pacing and recording. **Similarly, deflectable quads were advanced through 7-French and 8-French sheaths to the RVOT and His positions, respectively.*


The presenting rhythm was sinus rhythm with a baseline cycle length of 1220 milliseconds. The PR was 100 milliseconds, QRS duration of 87, and Q-T of 333. The AH was 47 milliseconds with an HV of 62.


*Programmed stimulation was then performed in the ventricle and the atrium.* There was no clear VA conduction noted at baseline. The AV Wenckebach cycle length was 370 milliseconds. *Extrastimulus pacing was then performed from the atrium.* The AERP was 600/250 with AV nodal AERP less than or equal to 600/250. There was no evidence for an A2-H2 jump. Decremental extrastimulus pacing was then repeated with a drivetrain of 400 milliseconds. The AV nodal ERP was 400/220. 


*The patient was then started on Isuprel *at 1 mcg per minute. The AV Wenckebach cycle length was 350 milliseconds on 1 of Isuprel. This was then increased to 2 mcg per minute. 


With AV Wenckebach pacing on 2 mcg of Isuprel, t*he patient was noted to go into monomorphic VT with a right bundle*, left superior axis, R-wave transition at V4, with a tachycardia cycle length of 350 msec. *The VT was self-terminated.* The patient felt symptoms similar to her palpitations during the VT. She did not become hemodynamically unstable prior to the spontaneous termination.


Given the patient's easily inducible monomorphic VT with no inducible SVT, t*he decision was made to pursue pharmacologic treatment of the patient's ventricular tachycardia.
* _(so no ablation)_

At the conclusion of the procedure, catheters were removed under fluoroscopic guidance. Sheaths were pulled and hemostasis achieved with manual pressure. The patient was then transferred to the recovery area in stable condition.


The patient's device was reinterrogated, and the tachycardia parameters were adjusted based on the findings of today's EP study. The VT zone was decreased to 165 beats per minute, and a monitor zone was also added.


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