# cardioversion w/ICD insertion



## schmsuz (Nov 17, 2016)

Can cardioversion be billed during the insertion of an ICD system?  Thank you for your help!


PROCEDURES: 
1.  	Explantation of old single-chamber ICD generator.
2.  	Capping of chronic nonfunctioning ICD lead on the left pectoral region.
3.  	Implantation of new dual-chamber ICD system on the right pectoral region, Medtronic system.
4.  	Direct current cardioversion of persistent atrial fibrillation.

INDICATION: A 65-year-old white female with history of nonischemic cardiomyopathy with congestive heart failure. She had prior single-chamber ICD implantation several years ago. She, however, was admitted recently for congestive heart failure exacerbation due to sick sinus syndrome with severe sinus bradycardia as well as recurrent atrial fibrillation, despite amiodarone therapy. She had been treated with Eliquis. She undergoes ICD upgrade today. The previous ICD lead was known to have chronically elevated pacing threshold. 

DESCRIPTION OF PROCEDURE: An informed consent was obtained, the patient was brought to the cardiac cath lab in a fasting state. The left pectoral region was then prepped and draped in usual sterile fashion. 1% Xylocaine was used to infiltrate the area. A transverse incision was then made and blunt dissection was then performed to isolate the ICD capsule, which was then opened. The old ICD generator was then disconnected from the chronic ICD leads. Attempt to access the left subclavian vein was made. However, the guidewire could not pass the entry site of the prior ICD lead due to chronic occlusion. Therefore, it was decided to implant the new system on the right pectoral region. The old ICD lead was then capped. The wounds were then sutured with the subcutaneous fat layer was sutured with 4-0 Vicryl suture and the wound was then sealed with Dermabond. 

The right pectoral region was then infiltrated with Xylocaine. The right subclavian vein was then accessed at 2 separate puncture sites to allow for insertion of 2 retaining j guidewires after the vein was visualized by peripheral contrast injection. A transverse incision was then made and blunt dissection was then performed to create an ICD pocket. Under fluoroscopic guidance, the leads were then introduced and maneuvered into respective chamber. The ICD lead was Medtronic model #6935M55, serial #TDL219284V. It was maneuvered into the right ventricular apex and initially fixated to the apical region. However, the R wave amplitude was low and therefore the lead was then maneuvered to the apical septal region and actively fixated there. At this site, the R wave amplitude was about 18 mV, with ventricular pacing threshold of 0.5 v, at 0.4 ms pulse width. The lead was then secured to the fascia using 2-0 silk suture. The atrial lead was then introduced. It was Medtronic model #5076, serial #PJN433255H. It was maneuvered into the right atrium and actively fixated into the appendage area. The P wave amplitude was about 2 mV, with atrial pacing threshold of 1.25 v, at 0.4 ms pulse width, with the impedance of 532 ohms. The leads were then secured to the fascia using 2-0 silk suture. The ICD pocket was then flushed with antibiotic solution and was inspected. It was clean and dry. The leads were then connected to the ICD generator, Medtronic model #DDBB1D4, serial #DWB229906H. The system was then placed into the ICD pocket and the generator was then secured to the fascia using 2-0 silk suture. Closure was then performed. The subcutaneous fat layer was closed with 4-0 Vicryl suture and the wound was then sealed with Dermabond. The sponge and needle counts were correct. The patient tolerated the procedure well and there were no complications. 

It should be noted that after insertion of the atrial lead, the patient was then consciously sedated with fentanyl and Versed and was cardioverted back to normal sinus rhythm from atrial fibrillation with 360 joules synchronized shock.


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## jtuominen (Dec 1, 2016)

Here are the rules I use to determine whether or not I can bill for an external cardioversion (92960) that occurs in proximity to a device procedure:

1. It has to an elective cardioversion--meaning everyone was aware ahead of time it was going to be done. There is a separate consent form signed by patient/guardian for it, or the consent explicitly ID's patient is going to also have an external cardioversion today.
2. It has to occur either prior to or after the device procedure has occurred. It has to be blatantly clear that the cardioversion was not done intraprocedurally--meaning not in the middle of finishing the device implant/replacement procedure. You should have your docs make a clear statement that it occurred before or after (probably after is more likely, and therefore I would look for a statement that the leads were connected to gen, everything was back in the pocket, and the patient is already sutured up).
If these conditions are met, then I would bill 92960-XU/59 additionally.

In your case scenario, I would have to say I might not bill it additionally. The doc says he did the cardioversion after installation of the RA lead. This calls into question whether or not they truly had completed the device implant procedure, because the body of his note recalls that a couple of other things happened after the RA lead was placed.

So after reading your note I'd probably code:
33241: Left sided gen explant
33249: Right sided gen insert plus new RA and RV lead insert

nothing for the capping of old lead, no cardioversion charge.


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## schmsuz (Dec 1, 2016)

Thank you so much!


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