# cardioversion - atrial septostomy



## superorozco (Apr 30, 2009)

Hi everyone,
I need help figuring out if I should bill the 92961 or just the CPR 92950 during an atrial septostomy(92992) or should i use the unlisted? Also would be billing 36555 

Here is the report:
PROCEDURE PERFORMED:
1. Right and left heart cardiac catheterization.
2. Balloon atrial septostomy under echocardiographic guidance.
3. Cardioversion.
4. Placement of right femoral triple lumen.

MEDICATIONS:  Fentanyl, Versed, vecuronium.  Sedation with Versed drip.

ESTIMATED BLOOD LOSS:  Less than 10 mL.

COMPLICATIONS:  Atrial flutter which required electronic cardioversion

DESCRIPTION OF PROCEDURE:  This is a 1-day-old baby born last night with a
prenatal diagnosis of transposition of great vessels.  The patient had started with a desaturation early this morning.  The preductal saturations were dropping below the 60s and with 100% FIO2 and adequate blood pressure, for which Dr. was contacted and was requested to do Rashkind balloon (balloon atrial septostomy).  Dr. met with mother and discussed risks and benefits of the procedure.  The risks included but were not limited to cardiac or vessel injury causing bleeding requiring blood transfusion and/or emergency surgery, arrhythmia, infection, heart block, air or clot embolization causing heart attack or stroke, etc.  She understood the risks and benefits well.  She asked many appropriate questions.  The consent forms were signed.  The patient was given a fentanyl and Versed bolus as well as given vecuronium.  Both groins were prepped in the usual sterile fashion.  Right femoral vein was accessed with ease.  A  7-French sheath was placed.  Through this sheath, catheters were introduced and the procedure was done.  At the end of the procedure the sheath was removed and was replaced with a 5-French 8-cm-long triple lumen.

SATURATION DATA:  No saturations were obtained but multiple blood gases were done before the procedure, as well as during procedure and after procedure.

PRESSURE DATA:  UAC art line pressure was monitored with other parameters of EKG.  The blood pressure was kept more than 60 mmHg systolic throughout the whole process.
DESCRIPTION OF INTERVENTIONAL PROCEDURE:  Description of balloon atrial
septostomy (Rashkind procedure):   After obtaining access under  echocardiographic guidance, a  Rashkind catheter was introduced.  This catheter was advanced into the right atrium.  Subsequently under echocardiographic guidance, the catheter was advanced into the left atrium.  Once in the left atrium, the balloon was inflated slowly while confirming its position in the left atrium away from the left atrial appendage as well as from the mitral valve.  After confirming its position, the balloon was inflated to 3 mL. Subsequently again echocardiographic confirmation was made of the balloon not in the mitral valve as well as away from the atrial appendage.  Subsequently the balloon was pulled back and into the right atrium and immediately deflated. With this maneuver the patient went into atrial flutter with a heart rate of 270.  The blood pressure remained stable with systolic pressures to be in the high 50s.  Subsequently the patient was hooked up on the defibrillator and 2 joule shock was given.  With this shock the patient converted immediately to sinus rhythm.  Subsequently EKG was done and the sinus rhythm was confirmed. Echocardiography was also done and confirmed no pericardial effusion as well as no mitral regurgitation as well as patency of IVC.  Subsequently the balloon was advanced again to the right atrium to atrial septum into the left atrium. Subsequently a 4 mL balloon was inflated and again another pull was done under echocardiographic guidance after taking all the previously described precautions.  Subsequently echocardiography was done and again confirmed no pericardial effusion as well as no mitral valve regurgitation and IVC patency. Subsequently the balloon was taken out.  The sheath was aspirated.  Subsequently
a wire was placed through the sheath, and sheath was taken out and was replaced for a 5-French 8-cm-long triple lumen.  This was sutured in place.
CONCLUSION:
1. Newborn with transposition of great vessels.
2. Successful balloon atrial septostomy.
3. Atrial flutter with atrial septostomy, successfully converted with
cardioversion.


Thank you!
Kathy Orozco,CPC


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## deeva456 (May 4, 2009)

Hi,

Since the patient was in atrial flutter and not cardiac arrest, I would bill for the cardioversion, 92960 with dx 427.32.  Depending on who the payer is, you may need to add modifier 59 to 92960.

I hope this has helped,

Dolores, CPC, CCC


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