# A doozie of a cath



## Robbin109 (Oct 14, 2012)

After informed consent, the pt was brought to the cardiac cath lab where under general anesthesia, a transesophageal probe was advanced  in position for guidance along with fluoroscopy.  After the patient was anesthetized with the endoscopy probe in position  arterial and venous access was obtained first in the left femoral artery, #6-French sheath for blood pressure monitoring and then on the right side, an 8 French arterial introducer in the right femoral vein.  After obtaining arterial and venous access attention was turned to the subxiphoid space where as prescribed using a special needle, the pericardial sac was accessed and 0.35 wire was advanced under fluoroscopic control around the silhouette of the heart.  After confirming no intercavitary position of the wire, a 14-French sheath was advanced into the pericardial space.

After completion of the access with the dry pericardial tap of the pericardial cavity, attention was then turned to the endovascular space were through the 8-French initial femoral vein access, a SL1 St. Jude Medical transeptal system was advanced and under fluoroscopic control as well as echocardiographic guidance, the left heart was access through the left atrium via interatrial septal puncture.With now the transeptal sheath in good position near the origin of the left atrial appendage multiple injections were taken in various projections confirming the anatomy both of the atrium and of the left atrial appendage.

After clear opacification of both cavities, the endovascular magnet wire was advanced through the transeptal sheath into the left atrial appendage and positioned in a distal anterior position as desired under both fluoroscopic as well as echocardiographic guidance.
Over the wire, a 15 mm SentreHEART balloon was advanced and inflated to 1 mL.  Wtih the balloon now at the level of Coumadin ridge, mostly in the left atrial appendage cavity, attention was then turned to the pericardial sheath where a second magnet wire was advanced up the pericardial space meeting the endovascular wire and connecting nicely.  With both wires touching with a full loop performed from the endo to the epicardial space, the Lariat device was advanced over the epicardial wire over the left atrial appendage and then synched appropriately. with the device synched the balloon in the left atrial appendage along with the endovascular wires were removed and full synching was obtained verifying under transesophageal echo cessation of flow into the left appendage cavity. At that time, after confirming good synching with 5 minutes of waiting period, the entire pericardial sheath setup was removed.  The Lariat suture was cut and the procedure was concluded.

After a few minutes of observation, the transeptal cath was removed leaving a 9-french sheath in position in the right femoral vein.  The patient was transferred in stable condition with no evidence of hemodynamic compromise with a small pigtail catheter in the pericardial cavity first to the post-anesthesia recovery and assuming the patient remains stable after removal of the sheath, he would be transferred to the ICU unit for overnight care until the pericardial catheter is removed.  


93452
93462
93318 ??
93566 ??


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## Misty Dawn (Oct 14, 2012)

The dictation talks about a Lariat device.  This is used for pt with Afib to tie off the left appendage to stop clots from going to the brain.   If you find a better let me know.  Seems like a fairly new procedure so 33999?  Post back if you find a code for this procedure but I don't think the HTC codes would be used.  

Misty Sebert, CPC     
Coding Specialist/Hospital Coordinator    
Spokane Cardiology  Providence Heart Institute


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## jewlz0879 (Oct 15, 2012)

I agree with Misty. It seems to me he's doing a left atrial appendage. 

Here is what I found from STS:

1. Left Atrial Appendage (LAA) can be billed separately with CABG or other cardiac procedures except: MAZE and Mitral Valve repair/replacement; that is because LAA is considered to be an integral part of those procedures. 

2. If LAA is performed to remove thrombus, then code 33310/33315 appending -59 and -51 modifier. 

3. If the LAA is done for any other reason and not part of a MAZE OR MVR then it should be reported using the unlisted code, 33999. 

When we bill unlised codes, we create a "key code" (just an internal identification system) so we know what the unlisted code is referring too. For this one, we use, 3399 - LA.


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## Robbin109 (Oct 15, 2012)

Thank you.


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## Robbin109 (Oct 15, 2012)

So you would code the 33999 and the echo?
93318? or no?

What price should I charge for this?


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## Robbin109 (Oct 15, 2012)

So you would code the 33999 and the echo?
93318? or no?

What price should I charge for this?


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## Robbin109 (Oct 15, 2012)

I just found this:

0281T   Percutaneous transcatheter closure of the left atrial appendage with implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, radiological supervision and interpretation  

Would this apply and what insurances take Catagory 3 codes...or should I use the unlisted code?


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## jewlz0879 (Oct 15, 2012)

I would code only 33999. It is my opinion the TEE was done as mapping guidance and not from a diagnostic perspective. 

You will have to use a comp code to figure price. I want to say we used CPT 33310 for non-bypass and 33315 with bypass.


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## Robbin109 (Oct 15, 2012)

Thanks, I was just looking into the procedure a bit more and it is making more sense now. Thanks.


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## Misty Dawn (Oct 16, 2012)

Here is a short vidoe that describe the procedure for pts with afib http://texasheart.org/AboutUs/News/2011-01-25news_lariat.cfm  Sorry I don't know if the TEE would be included or not.


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