# aortic valve replacement with modified maze procedure and pulmonary vein isolation



## aholmes2022 (Mar 28, 2013)

Could someone please help me, i would like some advice regarding a op note i am coding?



My question is how should i be capturing the pulmonary vein isolation. I dont have anything leading me to believing it is part of the modified maze. Maybe it is inclusive to the AVR but i am unsure.  There is no code only for pulmonary vein isolation alone without getting into Comprehensive EP and the patient does not have any other elements of the cpt code 93656.  I do not feel billing for 93656 even with a 52 modifier is appropiate

I am leaning towards 33405,33257 and 93631

Please help!!

Please see op note below:

DIAGNOSES:  Aortic stenosis, aortic insufficiency, and atrial flutter,
status post ablation.
PROCEDURES:
1.  Aortic valve replacement, 29-mm mosaic bioprosthetic valve.
2.  Modified maze procedure with bilateral pulmonary vein isolation,
ligation of left atrial appendage, and epicardial mapping with exit block
bilaterally with no evidence of positive lesions.
PROCEDURE IN DETAIL:  After obtaining consent, the patient was brought to
the operating room and placed on the operating room table in supine
position.  General endotracheal anesthesia was obtained.  Chest, abdomen,
and lower extremities were prepped and draped in sterile fashion.  Median
sternotomy was performed.  Skin and subcutaneous tissues were divided with
a #15 blade presternal fashion.  Linea alba was divided with Bovie cautery.
Sternum was divided in the midline with a saw.  Sternotomy retractor was
positioned.  Pericardium was opened.  Adequate ACT was confirmed with
significant amount of pulmonary hypertension and appearing to have some
right heart failure.  He was cannulated for cardiopulmonary bypass again
after confirming adequate ACT and as described above determined that
additional ablation of pulmonary veins was appropriate and warranted.
After safe placement of cardiopulmonary bypass, antegrade cardioplegia was
delivered followed by retrograde in addition to hand-held ostial perfusion.
Aortotomy was performed.  The valve was trileaflet, degenerative with heavy
central calcification and fusion of the left and right coronary cusps at
the level of commissure.  The leaflets were excised and sent to pathology
for evaluation.  He excised appropriately for a 29 mm valve.
Circumferential sutures were placed.  A left-sided maze was performed.  The
left-sided pulmonary veins were isolated.  The autonomic ganglia were
divided.  The ligament of Marshall, the left atrial appendage was excised
with an Endo-GIA stapler.  The sutures were then brought through the valve.
The valve was dropped in to position.  Aortotomy was closed in two layers
with rewarming the right-sided pulmonary vein isolation was performed.
After adequate dissection when the patient resumed a rhythm, mapping was
performed on the left and right sides.  We could not place a rapid sequence
induction or exit block confirmation.  There was no positive response.
With resumption of rhythm, the patient was weaned from cardiopulmonary
bypass after resuming ventilation.  This went without difficulty.  He was
decannulated.  Cannulation sites were reinforced with Prolene suture.
Ventricular pacing wires were placed as were two mediastinal and one
pleural drainage tube.  With confirmation of hemostasis, the chest was
closed in a standard fashion with the addition of figure-of-eight central
cables due to the patient's size at 6 feet and 4 inches and a body surface
area of 2.7.   The remainder of
the closure was per routine with 0 Vicryl for the linea alba and sternal
fascia, subcutaneous tissue and 4-0 for the skin.  The patient tolerated
the procedure well and went to intensive care in stable condition.


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## jewlz0879 (Mar 28, 2013)

The EP studies are done percutaneously and the MAZE is open, yet both are to ablate sustantained dysrhythmias; your code choice is in the right area. 

The PVI (pumonary vein isolation) is included in the limited code so no need to bill separately for it. 

To qualify for "extensive" must meet only one criteria described under the second bullet (pg. 180 CPT Professonal) - 'ganglion plexi' or 'ligament of Marshall'  are indicative or an extensive MAZE. 

I would go with 33405 & 33259 (with CP bypass)

HTH


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## aholmes2022 (Mar 29, 2013)

Thanks for your help


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