# 93620, 36556



## amym (Jan 28, 2013)

Insurance bundled CPT 36556 into 93620.  According to the NCCI edits they are bundled but are there any exceptions to the rule.  I wanted to make sure before we write off the charge.

Procedure:  History and physical exam were performed in the fasting 
state and patient was brought to the electrophysiology 
laboratory and the procedure indications and potential 
complications, including, but not limited to, bleeding, deep venous 
thrombosis, infection life-threatening cardiac tamponade, damage to 
the conduction system necessitating pacemaker, aspiration and 
advanced medication reaction and alternatives available were 
explained to the patient.  She appeared to understand and indicated 
the same.  An opportunity for questions was provided and informed 
consent obtained.  Under local anesthesia, the right femoral vein 
was percutaneously cannulated using Seldinger technique, and one 7- 
French and one 8-French sheath were introduced.  Later in the case, 
8-French sheath was exchanged over the wire for a small Agilis 
steerable sheath for more support for the mapping catheter.  A 
deflectable Duo-Deca catheter was placed into the coronary sinus and 
looped around the right atrium and was used for mapping, recording, 
and pacing in the left and right atrium.  The other sheath was used 
to place an 8 mm large curve St. Jude Medical mapping and ablation 
catheter in the right atrium.  The patient's baseline rhythm at this 
time was atrial flutter with a PCL of 250 msec.  The flutter circuit 
was mapped and the area of slow conduction was found to be in the TV- 
IVC isthmus region.  Atrial activation sequence was consistent with 
counterclockwise right atrial flutter.  Frame of mapping was 
performed which confirmed the diagnosis.  A temperature guided 
mapping and ablation catheter was placed and presystolic atrial 
activity was localized to the cava tricuspid isthmus in the CS 
ostium and the inferior vena cava.  A number of radiofrequency 
ablations were applied in anatomic fashion to this area with 
successful termination of atrial flutter during RF delivery.  Post 
ablation atrial flutter was not inducible with full atrial 
stimulation protocol off and on Isuprel up to 2 mcg/minute. 
Creation of bidirectional conduction block across the TV-IVC isthmus 
area was demonstrated by pacing from the CS os and lower lateral 
right atrium.  At the end of the procedure, catheters and sheaths 
were removed and hemostasis obtained. 

Post ablation, the right atrial trans-isthmus conduction times were 
as following: 

1. Lateral to medial conduction time of 160 msec. 
2. Medial to lateral conduction time 162 msec. 

Before pulling the catheters, the mapping catheter was positioned at 
his location and integrity of AV conduction was checked.  AH was 80 
msec and HV was 52 msec.  Mapping catheter was advanced into the 
right ventricular apex and pacing from the RV showed VA block cycle 
length around 400 msec. 

Complications:  None. 

Comment: 
1. Successful flutter mapping and ablation with restriction of 
      sinus rhythm. 
2. The patient will be restarted on anticoagulation with heparin 
      6 hours after the procedure and her Coumadin will be initiated 
      tonight.  She will need at least 4 weeks of anticoagulation 
      with Coumadin.


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