# Help with coding pacer report



## jlb102780 (Jun 2, 2010)

Hi everyone. Can someone help with coding this report. I don't see these cases too often. Thanks in advanced!! 

Here's how I coded it:
33233         DX:996.01
33213              996.01
71090-26         996.01
33210-59         427.81
71090-26,59     427.81

NAME OF TEST:                                                                 
   1. DDDR permanent pacemaker battery change out.                            
   2. Insertion of a transvenous temporary ventricular pacemaker via the      
       right femoral vein.                                                    

HISTORY                                                                       
The patient is a very pleasant, 80-year-old male who has a history of sick    
sinus syndrome and complete heart block.  He had a Medtronic permanent        
pacemaker implanted by me back in 2002.  He has been followed in our office   
regularly.  He was seen in the office and noted to be at elective             
replacement.  He was brought in to have a DDDR permanent pacemaker battery    
change out procedure performed.  The patient was noted to be pacemaker        
dependent in the ventricular chamber.  Arrangements were made for the patient 
to have a temporary pacemaker placed as well.                                 

PROCEDURE                                                                     
The patient was brought to the cardiac catheterization laboratory in very     
stable condition.  Both groins were prepped and draped in the usual sterile   
fashion.  Both subclavian areas were prepped and draped as well. We first     
turned our attention to the right femoral area.  Using 1% Xylocaine, the      
right femoral area was anesthetized.  The patient was given some intravenous  
sedation.  Please see the accompanying nursing data sheet for full details    
regarding his sedation.  We then successfully cannulated the right femoral    
vein and a 6 French sheath was placed without difficulty.  A 5 French         
temporary ventricular pacemaker catheter was then placed without difficulty   
in the right ventricle.  Excellent thresholds were obtained.  We then placed  
the temporary pacemaker at a backup rate of 50 beats per minute on full       
demand pacing.                                                                

We then turned our attention to the left subclavian area.  I exchanged out    
for a new sterile gown and new sterile gloves.  Using 1% Xylocaine, we        
anesthetized the left subclavian area in the subcutaneous tissue over the old 
permanent pacemaker pulse generator.  Using a scalpel, a 4 cm horizontal      
incision was then made into the subclavian area over the old permanent        
pacemaker pulse generator.  The pacemaker capsule was then entered.           
Utilizing a curved hemostat, I was able to dissect out the old permanent      
pacemaker pulse generator from the pacemaker capsule.  The old permanent      
pacemaker pulse generator was then brought out to the surface of the skin.    
We then disconnected both leads from the old permanent pacemaker pulse        
generator.  We checked thresholds on both leads.  From the atrial lead they   
were as follows:                                                              
   1. Voltage 0.4 volts.                                                      
   2. P wave 4.1 millivolts.                                                  
   3. Resistance 513 ohms.                                                    

These thresholds in the atrial lead were thought to be quite good, especially 
for chronic thresholds.  I then checked the thresholds on the ventricular     
lead.  They were as follows:                                                  
   1. Voltage 0.7 volts.                                                      
   2. R wave 8.5 millivolts.                                                  
   3. Resistance 972 ohms.                                                    

These thresholds were also thought to be quite good with regards to the       
ventricular lead as well.  We then irrigated out the pacemaker pocket very    
vigorously with antibiotic solution.  I took a piece of 4 x 4 gauze and       
saturated it with antibiotic solution.  I then proceeded to wipe down both    
pacemaker leads very carefully as well as then new permanent pacemaker pulse  
generator.  We connected the new permanent pacemaker pulse generator to both  
leads.  I documented adequate capture in both leads.  We then used the        
sterile programming head in order to program the new permanent pacemaker      
pulse generator.  During this time, the new permanent pacemaker pulse         
generator and excess pacemaker leads were placed in the pacemaker pocket.     
The subcutaneous tissue was closed in an interrupted layer of 2-0 Vicryl      
suture.  The skin was then closed with staples.  During this time, the        
temporary pacemaker leads was removed under fluoroscopy without difficulty.   

The explanted pacemaker was a Medtronic, model #KDR901.  The new permanent    
pacemaker pulse generator is a Medtronic Versa, model #VEDR01, serial         
#NWH223704H.  The pacemaker is set in the DDD mode at a lower rate of 60 and  
upper rate of 120 beats per minute.  Both chambers were set at nominal        
settings.  Both leads were set in a bipolar configuration.                    

CONCLUSION                                                                    
   1. Successful DDDR permanent pacemaker battery change out.                 
   2. Successful insertion of a transvenous temporary ventricular pacemaker   
       via the right femoral vein.


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## deeva456 (Jun 8, 2010)

Hello,

You are on the right track..however, I'm not sure about billing 71090-26 twice; if it is allowed or payable, add modifier 76. see below. I dont know of any specific coding rules for the diagnosis as far as needing add'l codes. In this case you could add 427.81 & 426.0 with V53.31.  Some payers will not pay on claims using "V" codes. 

33233 DX:V53.31
33213 V53.31
71090-26 V53.31
33210-59 427.81, 426.0
71090-26,76-59 427.81, 426.0

I use V53.31 for "end of life" status of the pacemaker generator. In the index under _change(s) of - battery_ it shows this code.  996.01 is for mechanical complication, breakage or malfunction of the lead.  

996.01 -complications peculiar to certain specified procedures; mechanical complication of cardiac device, implant, and graft; *due to cardiac pacemaker (electrode)*

I hope this makes sense.


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## jlb102780 (Jun 15, 2010)

deeva456 said:


> Hello,
> 
> You are on the right track..however, I'm not sure about billing 71090-26 twice; if it is allowed or payable, add modifier 76. see below. I dont know of any specific coding rules for the diagnosis as far as needing add'l codes. In this case you could add 427.81 & 426.0 with V53.31.  Some payers will not pay on claims using "V" codes.
> 
> ...



Yes it does. Thanks a lot for your help


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