# CS venogram - PLEASE HELP!



## Brandi (Oct 26, 2015)

Any help on this would be greatly appreciated!
The doctor planned to do an upgrade from a dual to a mult-lead ICD...that was unsuccessful. The only thing I can bill for is the CS venogram.. which is usually bundled. How do I code a CS venogram alone?

Here's the procedure note:

	Procedure Orders:
	1. EP UPGRADE DEVICE TO BIV ICD

	Pre-procedure Diagnoses
	1. CHF (congestive heart failure), NYHA class III, chronic, systolic (HCC) [I50.22]
	2. Left bundle branch block (LBBB) [I44.7]

	Post-procedure Diagnoses
	1. Chronic systolic congestive heart failure (HCC) [I50.22]
	2. LBBB (left bundle branch block) [I44.7]

	Procedures
	1. EP UPGRADE DEVICE TO BIV ICD [EP28 (Custom)]

Procedure: Attempted upgrade to BIV ICD from DDD ICD
Diagnosis: CHF, systolic heart failure (chronic), LBBB (chronic pacing

EP laboratory for upgrade of existing dual chamber ICD to a biventricular ICD. Informed consent was obtained prior to the procedure start and conscious sedation was provided for the procedure by Anesthesia, which is detailed elsewhere. IV antibiotics were given prior to the incision and the left prepectoral area was prepped and draped in usual standard fashion. The area over the incision and pontic were anesthetized with Pontocaine and the incision was opened with a plasma blade. The incision was carried down to the chronic pocket and the leads and pulse generator were liberated. The pulse generator was removed from the pocket and the ICD lead in the right atrial lead were freed of adhesions. Subclavian access was obtained and a wire was passed under fluoroscopic guidance into the central circulation. A Worley sheath was advanced into the right atrium and used to cannulate the coronary sinus. Cs access was challenging and a decapolar coronary sinus diagnostic catheter was used to cannulate the Cs. We could not advance the Worley sheath over the decapolar catheter due to tortuosity at the ostium of the coronary sinus and eventually the Worley sheath was exchanged for a Medtronic and V2 sheath. Once coronary sinus was cannulated, a venogram was performed which showed a very large and ectatic coronary sinus with no anterolateral, mid lateral or posterolateral branches. We used a Whisper wire and a Medtronic 4398-88, serial number QUB 14135 V trying to engage in anterolateral branch to no avail. There was a small mid lateral branch but it was not large enough to hold the lead and we were unable to cannulate anything in the posterolateral circulation this, we withdrew through the Cs sheath. It was decided at this point that we will make an attempt for hiss bundle pacing and the Cs sheath was exchanged for a short 9-French peel-away sheath and a Medtronic 3830-69, serial number LFFO98174 V was advanced in the central circulation. We were unable to gain acceptable capture thresholds along the intraventricular septum or show any clear evidence of hiss bundle capture. At this point in time, it was decided to refer the patient for thoracoscopic LV lead placement. The right atrial lead and right ventricular lead thresholds were checked and impedances were stable from chronic and there was six years left on the Incepta Boston Scientific and Incept ICD-E 163 serial number 104221. The pocket was copiously irrigated with antibiotic solution and hemostasis was obtained. The pocket was closed with 2 layers of absorbable suture and the skin was approximated with Prolene suture. There were no acute complications.

PROCEDURE SUMMARY: Unsuccessful CRT ICD upgrade with plans to refer for surgical lead placement and submuscular pocket revision.


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## jenneverett (Oct 28, 2015)

I would code it with  33264-53, because it was attempted with the incision of the pocket and removal of the device and then the device was put back in without the additional lead. I would put a comment in line 19 of the claim if you are filing electronically or send the report with the claim if you are dropping the claim to paper.

Hope that helps.

Jennifer Everett, CPC


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## Margaret Morgan (Oct 29, 2015)

I am not sure I agree with the above post.  I would verify that a new ICD generator was placed before billing a 33264.  The report suggest to me that the old generator was put back into the patient having 6 years left on it.  I would have queried the provider weather or not a new ICD generator was implanted.  
Regarding the attempted LV lead implant, I would bill for it with a 33225 or 33224 based on the physician answer regarding which generator was implanted the same generator or a new one.

same generator implanted I would bill:
33224-52

New generator implanted I would bill:
33264 
33225-52

Your physicians did all the work of a LV lead placement, but they were unable to access a branch of the CS vein that gave good therapy.  I believe 52 is the better modifier as not all the procedure was completed but most.

Sincerely,
Margaret


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## vickynelu (Oct 31, 2015)

My opinion 33264, 33224 mod 53. The BI-V upgrade was attempting but not finished and the generator was removed and replaced. Ask the physician if was replaced the old generator (6 years left). 
I would like to hear more opinions.

Sincerely,

Vicky D, CPC-P


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