# pacemaker insertion



## bhargavi (Jul 9, 2015)

OPERATION PERFORMED                                                             
1.  Implantation of dual-chamber rate responsive permanent pacemaker system via 
left subclavian vein.                                                           
2.  Right subclavian double-lumen central line insertion right subclavian vein. 

SURGEON                                                                         
Dr.                                       
ANESTHESIA                                                                      
Was MAC                                                                         

COMPLICATION(S)                                                                 
None.                                                                           

ESTIMATED BLOOD LOSS                                                            
6 ml                                                                            

PREOPERATIVE DIAGNOSIS(ES)                                                      
1.  Poor intravenous access.                                                    
2.  Syncope.                                                                    
3.  Mobitz II second-degree atrioventricular block.                             

POSTOPERATIVE DIAGNOSIS(ES)                                                     
1.  Poor intravenous access                                                     
2.  Syncope.                                                                    
3.  Mobitz II second-degree atrioventricular block.                             

HARDWARE IMPLANTED                                                              
1.  Medtronic Adapta DR model number ADDR01, serial number NWBC301842H.         
2.  Medtronic active fixation right ventricular lead, model number 4076 - 58,   
serial number BBL 1081469.                                                      
3.  Medtronic active fixation right atrial lead, model number 4076 - 52, serial 
number BBL 1080888.                                                             

OPERATIVE NOTE                                                                  
The patient brought to the electrophysiology laboratory in the postabsorptive   
state.  He had no intravenous access and his right upper chest was prepped and  
draped in usual sterile fashion and anesthetized with 8 ml of 1% lidocaine.  A  
double-lumen central line was placed in the right subclavian and anchored into  
place using 2-0 silk.  A separate prep and drape and scrub was performed and    
his left upper chest was anesthetized using 20 ml of a 50/50 mixture of 0.25%   
Marcaine and 2% lidocaine.  An incision was made medial to the deltopectoral    
groove and electrocautery was used to obtain hemostasis as well as to perform   
dissection down to the pectoralis fascia were a prepectoralis pocket was        
created.  Two separate subclavian punctures placed guidewires in the subclavian 
vein.  Tear away sheath introduced the leads into the superior vena cava where  
fluoroscopic guidance assisted placement of the active fixation right           
ventricular lead into the right ventricular apex which was then lifted into the 
distal right ventricular septum.  Pacing and sensing thresholds were obtained.  
The active fixation atrial lead was inserted into the superior vena cava where  
fluoroscopic guidance assisted placement of the active fixation atrial lead     
into the right atrial appendage.  Both leads were anchored into the pectoralis  
fascia using 0-Ethibond.  The R-wave was 17 mV, impedance 880 ohms with a       
threshold of 0.6 volts at 0.5 milliseconds pulse width.  The P-wave was 1.3 mV, 
impedance 617 ohms with a threshold of 0.7 volts at 0.5 milliseconds pulse      
width.  The device was left programmed MVPR 60 - 130.  The leads were secured   
to the device, placed in the pocket, and the incision closed in three layers    
after irrigation with an antibiotic solution and hemostasis.  The lower two     
were closed with 2-0 Vicryl and cutaneous with 4-0 Vicryl.  Steri-Strips and    
dry sterile dressing were placed over the wound.  The patient was transferred   
to the Postanesthesia Care Unit in stable condition for recovery from           
anesthesia.                                                                     





Absence of signature indicates                                                 
distribution before physician review   

 should i only bill 33208 or should i also bill 36569 for picc cath insertion because of no iv access?
thanks in advance                            










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## Jim Pawloski (Jul 10, 2015)

bhargavi said:


> OPERATION PERFORMED
> 1.  Implantation of dual-chamber rate responsive permanent pacemaker system via
> left subclavian vein.
> 2.  Right subclavian double-lumen central line insertion right subclavian vein.
> ...



Yes bill 33208 for the  pacemaker, but bill for a central line placement (same code as a quinton dialysis catheter), not a picc.
HTH,
Jim Pawloski, CIRCC


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