# Need help with a Code a Round



## dms979 (Jan 17, 2012)

I have the E & M coded and accepted with 99203 dx : 427.31 425.4 401.9 & 427.1     Have a problem with the interrogation of the device I thought I was correct with 93289. Any help would be appreciated.   Thank You

CHIEF COMPLAINT:  CAD, MI.

HISTORY OF PRESENT ILLNESS:  An 85 year old male new patient who has a history of coronary artery disease with previous myocardial infarction and inducible monomorphic ventricular tachycardia. He has a dual chamber cardio defibrillator model and a dual chamber cardioverter with an atrial lead.  He presents for evaluation recent myocardial infarction and inducible monomorphic ventricular tachycardia. He was walking in his house when suddenly without warning his device fired. He had no symptoms of palpitations or heart racing prior to the event. He felt the same before and after the event other than the anxiety related to shock. His device was interrogated and demonstrated the shock occurred for atrial fibrillation with a rapid ventricular response. This resulted in slowing of his ventricular response but did not convert him from his chronic atrial fibrillation. As a result of this shock his Inderal has been increase from 80 mg once daily to 120 mg daily. He does not notice any difference in the increased dose of Inderal. He has no symptoms of chest pain or angina. He has mild symptoms of exertional dyspnea and NYHD Class II symptoms, but no symptoms of rest dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or edema. He has no chest pain or angina.

MEDICATIONS:  The patient's medicines were reviewed and include Inderal LA 120 mg daily, Cozaar 25 mg daily, aspirin 325 mg daily, a multivitamin one daily, and Valium as needed.

EXAMINATION:
Vital Signs: Pulse 78 BPM and irregular; Blood Pressure 118/74; Respirations 16; Height 5' 6”; Weight 165 lbs.
CARDIOVASCULAR:  The cardiac apex is not displaced. The first and second heart sounds are normal. There is a grade systolic murmur of mitral insufficiency. The JVP is normal at 3 cm. The carotids have normal upstrokes without bruits. 
RESPIRATORY: The chest expands normally. There is good air entry to both bases. No adventitious sounds are heard.

LABORATORY DATA
His device was evaluated and his battery voltage is currently 2.64 volts with a replacement indicator at 2.62 volts. His atrial fibrillation is noted with a ventricular response about 80 bpm. An echocardiogram from August 21, 2009, showed a dilated left atrium at 4.9 cm. His left ventricular function was normal with an ejection fraction of 60%.

IMPRESSION:  1) ICD Shock Secondary to Atrial Fibrillation with Rapid Ventricular Response.  2) Normal Functioning Cardioverter Defibrillator - Nearing End of Life.  3) Ventricular Tachycardia.  4) Coronary Artery Disease.  5) Dilated lschemic Cardiomyopathy - EF 60%, NYHD Class II.  6) Hypertension.  7) Allergy to ACE inhibitors.  

RECOMMENDATIONS:  This gentleman received an implantable cardiac defibrillator shock because of a rapid response from his underlying atrial fibrillation. He recently had his beta blocker dose increased but his ventricular response is still somewhat rapid and I have recommended he increase his Inderal to Inderal LA 80 mg twice daily. If hypotension ensues then lowering his dose of Cozaar would be appropriate. His CHADS2 score is only one so I would continue with Aspirin for his anticoagulation. It is interesting to note that the defibrillator shock did not convert his atrial fibrillation to sinus again supporting the idea that this is chronic atrial fibrillation. He should have his defibrillator changed when he reaches elective replacement indicator of 2.6 to volts. I will be pleased to change out his device at the appropriate time. I hope this letter is useful to you in the management of this patient


----------



## maryawinfield04 (Jan 17, 2012)

What exactly is the problem you're having with procedure 93289? is it denying for medical necessity? does your provider own the equipment? if he doesn't then you need to append a 26 modifier


----------



## dms979 (Jan 17, 2012)

This is an example of a report I have from the Code a Rounds. the computer accepted my E&M along with dx's as being correct. but the computer says I have incorrect code for 93289 interrogation of device have entered it with & without 26 modifier and now I'm at a loss as to what is the correct code.  These code a rounds aren't as easy as I thought they would be. This is my first time ordering them


----------



## agaluski (Jan 17, 2012)

My only suggestion we be to use 93283 because the note specifically states the patient has a dual ICD and the term "evaluate" is used in the laboratory data which does not really fully explain what parameters were checked or if any were changed. Also, I have never tried Code a rounds myself so if they are payor specific you may need to add a modifier 59 to the interrogation since you said it accepted 99203 alone for the visit. Hope this helps!


----------



## dms979 (Jan 20, 2012)

Thank you for your response. Still researching for the answer


----------



## Misty Dawn (Jan 22, 2012)

I think you are missing the CAD dx.  Do not code for the device eval because there is not enough dictation to bill for the interrogation. 

Implantable cardioverter defibrillator: Programmed parameters, lead(s), battery, capture and sensing function, presence or absence of therapy for ventricular tachyarrhythmias and
underlying heart rhythm."
The full definition is in the introductory section of the CPT manual of the Cardiovascular 
Device Monitoring – Implantable Devices provides the following definition for interrogation device evaluations and requirements for each type of device.

Good luck   I still have some from months ago that I can't figure out


----------

