# transseptal puncture



## karbaker (May 6, 2013)

billed:
93561
93620 26 51
93462 2 units
93662 26
93623 26
93621 26
paid on all charges except 93462, denial dos not support frequency of charges, how should this of been coded????
DOS 8/9/2012
PROCEDURES PERFORMED:
1. Electrophysiology study.
2. 3-D mapping using the Carto-3 system.
3. Radiofrequency ablation for atrial fibrillation with wide circumferential
isolation of all four pulmonary veins.
4. Electrical cardioversion.
5. Double transseptal punctures.
6. Interatrial echo.
INDICATION: Persistent atrial fibrillation with failure of amiodarone, as well
as other medications.
INFORMED CONSENT: The risks and benefits of the procedure were explained to the
patient in detail. The patient agreed to proceed and signed a written consent.
ANESTHESIA: All of the procedures were performed under general anesthesia.
CATHETERS USED: Two #8-French vascular sheaths in the right groin, one SL-1
sheath, one Agilis sheath, one #7-French vascular sheath and one #8.5-French
vascular sheath and another #6-French vascular sheath were used in the left
groin. A spiral Lasso catheter was used for mapping the left atrium and
pulmonary veins. A CRD Cunard quadripolar catheter and Bard decapolar catheter
were utilized. An AcuNav catheter was used for the intracardiac echo.
TECHNIQUE USED: Using the modified Seldinger technique, access was obtained to
the right femoral vein and left femoral vein.
DESCRIPTION OF THE PROCEDURE: Under fluoroscopic guidance, the Bard catheter
was initially placed to the coronary sinus. The CRD Cunard catheter was then
advanced under fluoroscopic guidance in the RAO view and placed in the His
position. Thereafter, we proceeded with the intracardiac echo with the AcuNav.
The AcuNav was then advanced through the #8.5-French sheath under fluoroscopic
guidance and placed in the mid-cavity of the right atrium. One of the two
#8-French vascular sheaths was exchanged over a long wire for the SL-1 sheath.
The SL-1 sheath was then placed in the left brachiocephalic vein. We then
planned to proceed with the double transseptal punctures.
A BRK (Brockenbrough) needle was advanced through the SL-1 sheath to two fingers
from the proximal end of the sheath. In the LAO view, the entire apparatus,
Echelon sheath and Brockenbrough needle were withdrawn to the right atrium and
engaged in the fossa ovalis. With the help of the intracardiac echo and
fluoroscopic guidance, tenting of the fossa ovalis was noted. The needle was
advanced to the left atrial cavity and pressure was noted of the left atrium.
The dilator was advanced over the needle and the sheath was advanced over the
dilator. Both the needle and dilator were then removed. The blood aspirated
was oxygenated blood and flushing was done, confirming positioning in the left
atrial cavity. The second transseptal puncture was performed in the same way as
I just described. Later on one of the Echelon sheaths was exchanged over the
long wire for an Agilis sheath, which is a deflectable sheath. The Navistar
F-curve ThermoCool 4 mm tip catheter was advanced through the Agilis sheath.
The Lasso catheter was then advanced through the other Echelon sheath to the
left atrium. We then proceeded with formation of the geometry of the left
atrium and its pulmonary veins. The patient had a CT angiogram done previously
which revealed a common left pulmonary vein. The superior and inferior
pulmonary veins have a common ostium and two separate ostia of the right
pulmonary veins. After geometry formation, it was merged with the CT angiogram.
Thereafter, we proceeded to the radiofrequency ablation with wide
circumferential isolation of the pulmonary veins. There was less x-ray activity
in the left pulmonary vein noted, but no activity was found in the right
pulmonary vein. All four pulmonary veins were isolated by radiofrequency ablation.
As noted, the entire procedure was performed under general anesthesia. A
Thermostat catheter was placed to the esophagus and the temperature was noted
during the procedure. The temperature did not increase more than 0.5 degrees in
the esophagus during the ablation. At the end of the isolation of all the
pulmonary veins, the patient remained in atrial fibrillation. It was then
decided to electrically cardiovert the patient. Thereafter, all of the
pulmonary veins were noted and all of the pulmonary veins were isolated. At
this point, we decided not to do any further ablation.
The prognosis and results of this procedure were discussed with the patient's
family in detail and they understood.
During the procedure, the patient received intravenous _____________ and the
activated clotting time (ACT) was maintained at 302 and 350. There were no
immediate complications. During the procedure, intracardiac echo was also used.
At the end of the procedure, the intracardiac echo was used to confirm there was
no complication from the ablation. There was no pericardial effusion. All of
the catheters and mapping catheter were removed, with ablation catheter. The
long sheath was partially withdrawn. The patient left the EP lab under the
guidance of the anesthesiologist. Once the ACT is less than 150, the sheath
will be removed from the venous site.
IMPRESSION: Successful wide circumferential isolation of all pulmonary veins
with electrophysiology study, His bundle recordings and coronary sinus
recording, as well as intracardiac echo and 3-D mapping of the left atrium and
pulmonary veins. The patient tolerated the procedure well with no immediate
complication.


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## smiller (Jun 18, 2013)

Hello - this is what I would have billed:  

93656 (ablation w/ep study and pvi)
93613 (3D mapping)
93623 (IV drug infusion-isuprel)
93662-26 (intracardiac echo/ultrasound)
93615 (esophageal recording)

The transseptal puncture, comprehensive ep eval (93620-26), left atrial pacing and recording (93621-26) is included with the ablation (93656).


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## smiller (Jun 18, 2013)

Oooops, sorry - I just now noticed the dos (8-9-12) for this one.  I used this year's new ablation code.  I apologize.


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