# Correct codes?



## Jess1125 (Apr 2, 2013)

Please read below. In this case would it be 33207 and 33233 being billed? Thanks in advance:

PROCEDURE PERFORMED:
1.  Placement of an RV pacing lead.
2.  Removal of pacing pulse generator with replacement of a dual-lead pulse generator.


PREOPERATIVE DIAGNOSES:
1.  History of bradycardia with high degree of AV block.
2.  RV lead noise consistent with fracture.


POSTOPERATIVE DIAGNOSES:   
1.  History of bradycardia with high degree of AV block.
2.  RV lead noise consistent with fracture.
3.  Likely insulation failure of the RV lead.


ANESTHESIA:  Local Lidocaine and moderate sedation with intravenous Versed and Fentanyl.


SPECIMENS:  The patient's prior pulse generator was removed from the field.


ESTIMATED BLOOD LOSS:  Minimal.


COMPLICATIONS:  None.

INDICATIONS FOR SURGERY:  The patient is an 86-year-old woman with a dual-chamber pacemaker placed in 2011 for high degree AV block, who has a significant RV pacing burden, although is not pacer-dependent.  She has recently had multiple noise reversions on her device and was noted to have reproducible noise on the lead with isometric maneuvers.  She is referred for lead revision.


DESCRIPTION OF PROCEDURE:  The indications, risks, benefits, alternatives, and details of the procedure were discussed with patient, and she provided informed written consent.  The patient was brought to the electrophysiology laboratory where she was prepped and draped in the usual sterile fashion.  Right upper extremity venography confirmed a patent right subclavian system.


Lidocaine 2% was used to anesthetize the right pectoral region.  Using a scalpel, a 4 cm incision was made over the prior implantation scar.  Using blunt dissection and brief bursts of electrocautery, the device pocket was opened and the device and leads were freed from their adhesions.


The RA and RV leads were noted to have a suture over the leads directly without a collar.  There did appear to be insulation failure of the RV lead.  


The RA lead was removed from the pulse generator with the appropriate torque wrench.  The lead was tested and found to have appropriate sensing, threshold, and impedance values.  The RV lead was then removed from the pulse generator.  No impedance or sensing issues were detected from the bipolar, tip, or ring configurations.  Given the patient's history of noise and noise reversions and reproducible noise with isometrics, it was thought there was likely an intermittent all-or-nothing fracture.


The right cephalic vein was then isolated with blunt dissection and secured with 0 silk x2.  An 18-gauge Angiocath was then used to access the vein under direct visualization.  A Terumo Glidewire was then advanced to the level of the IVC under fluoroscopic guidance.  A 7-French sheath was then placed over the wire.  The new RV lead was then delivered to the RV septum shy of the apex under fluoroscopic guidance.  The active fixation mechanism was deployed.  Appropriate sensing, threshold, and impedance values were obtained.  The pacing morphology was very narrow, consistent with septal capture.  The sheath was then split and removed.  The lead was secured to the underlying tissue with 0 silk x2.

Hemostasis was then ensured in the pocket with further electrocautery.  The pocket was irrigated with copious Bacitracin and saline solution.  The new pulse generator was connected to the leads with the appropriate torque wrench.  The device and lead assembly were then placed in the cleaned pocket.  The prior RV lead was capped and buried in the pocket.


The pocket was then closed in 3 layers with 2-0, 3-0, and 4-0 absorbable suture material in the fascial, subcutaneous, and subcuticular layers, respectively.  Steri-Strips and a Tegaderm dressing as well as a pressure dressing were applied.


The patient tolerated the procedure well and was transferred to a monitored bed in stable condition.


IMPLANTED HARDWARE:  The pulse generator is a St. Jude model PM2210, serial number 7282337.  The RV lead is a St. Jude 1688TC, serial number DM127703.  The chronic RA lead is a St. Jude 1944, serial number BLX11860 implanted 7/15/2011.  The capped RV lead is a St. Jude 1948, serial number BLP14116 from 7/15/2011.  The explanted pulse generator is a St. Jude PM2210, serial number 7155430.


LEAD PARAMETERS:  Through the device, the RA lead senses 3.1 millivolts, threshold 1.0 volts at 0.4 milliseconds, impedance 460 ohms.  RV lead senses greater than 12 millivolts, threshold 0.75 volts at 0.4 milliseconds, impedance 630 ohms.  


DEVICE PROGRAM:  DDDR 60-120, paced AV delay of 250, sensed AV delay of 200.


The patient tolerated the procedure well.


Jessica CPC, CCC


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## theresa.dix@tennova.com (Apr 3, 2013)

Jess1125 said:


> Please read below. In this case would it be 33207 and 33233 being billed? Thanks in advance:
> 
> PROCEDURE PERFORMED:
> 1.  Placement of an RV pacing lead.
> ...



Jessica,
 Yes you are exactly right.


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