# Coding help - Insertion of a Boston



## willishm2012 (Jul 24, 2013)

I am coming up w/ the following codes: 
33262
33216
37197

but was also looking at the 33224 but I am not 100%. 

any help will be greatly appreciated. 



PROCEDURES PERFORMED:  Included: 
1.  Removal of subcutaneous left subcostal ICD generator, Medtronic model 6939, serial number TDA100519R.

2.  Removal of Guidant transvenous leads, implant date 12/23/1994

3.  Partial removal of the transvenous subclavian vein of ICD lead using Cook evolution system.

4.  Removal of the remainder of the ICD Fidelis lead via a right common femoral transvenous approach using Cook evolution lead extraction system.

5.  Patch repair of the right common femoral vein using bovine pericardium.

6.  Insertion of a Boston Scientific ICD, model Energen ICD DF4-VR, model E140, serial number 109499, subcutaneous position.

7.  Insertion of Boston Scientific Reliance ICD lead, model number Reliance 4-Site SG active fix, single coil, 64 cm, model 0293, serial number 114220.  Location RV.  The device measurements, the RV lead intrinsic 9.6 millivolts, threshold 1.0 V at 0.4 msec.  Impedance was 810.  Program parameters of 50 beats per minute, sensitivity 0.6 millivolts.

HISTORY AND FINDINGS:  The patient was a 60-year-old gentleman that had a Sprint Fidelis lead inserted in 1994 along with a placement of a left subcostal subcutaneous positioning of an ICD.  Generator had been changed on several occasions.  Recently, the patient was getting shocked and there was evidence of fracture of the right ventricular lead.  This lead had been brought up from the right subcostal area across the left side of the chest and entered the left subclavian vein.  Patient also had a subcutaneous lead in place.  This lead was divided, but the subcutaneous lead was left intact.  Removal of the Sprint Fidelis lead was partial via a left subcutaneous vein approach utilizing the Cook evolution device.  The major problem in removing it was the fact that the locking stylet could only be advanced approximately 4 or 5 inches. There was an obstruction within the Sprint Fidelis lead which made extraction quite difficult.  Eventually, only approximately half of the lead was able to be removed before the lead fractured.  The right common femoral vein was then punctured percutaneously initially and a basket retractor inserted from below.  This was partially successful removing the proximal end of the Sprint Fidelis lead and pulling it down into the common femoral vein where it could actually be manually grasped; however, the tip of the Fidelis lead remained firmly fixated in the right ventricle and would not move with traction.  Ultimately, the common femoral vein was explored with open technique.  The Cook evolution device was placed directly in the common femoral vein and the evolution device was deployed right to the very tip of the Sprint Fidelis lead.  This was the only way the lead would actually come loose.  The lead was completely removed intact.  There was, however, the venous sheath at one point was lost just proximal to opening in the femoral vein.  This necessitated gaining more proximal control of the vein and ultimately it was extracted through the opening in the common femoral vein and the vein was repaired with bovine pericardium.  Once this was accomplished, the procedure proceeded in a more standard fashion.  The left subclavian vein was repunctured and a new Boston Scientific lead positioned in the apex of the right ventricle with good pacing and sensing thresholds obtained.  Estimated blood loss was certainly more than anticipated because of the femoral approach at approximately 1500 to 2000 mL.  The patient did receive 1 unit of packed cells during the procedure, but was hemodynamically stable.

DESCRIPTION OF PROCEDURE:  An incision was made in the left subcostal area and the fibrous capsule was mostly excised. There was a subcutaneous lead that was divided and separated from the generator.  The Sprint Fidelis lead was divided as well.  A second incision was then made in the left infraclavicular area where a pocket was created and the remainder of the Sprint Fidelis lead was brought from the lower incision into the upper wound.  The lead was then divided and it was attempted to place an extraction lead into the lumen of the ICD lead; however, it would only advance approximately 4 or 5 inches.  This was the best we could do and it was secured in place.  The #13 Cook evolution sheath was placed over the lead extractor.  The Cook evolution was advanced along with the sheath to approximately the junction of the innominate vein and superior vena cava with the lead completely fractured.  At this point, in order to attempt to remove at least a portion of that lead, it was necessary to remove the sheath and therefore, access to the subclavian vein was lost on the left side.  There was no bleeding thereafter.  The options at this point were to leave the remaining half of the lead, which was now attached to the right ventricle in place in order attempt extraction from below.  The right common femoral vein was then punctured and the basket retractor and retrieval system inserted.  After multiple attempts, we were partially successful in that the proximal end of the fractured lead was able to be brought actually visually into the right groin where it was grasped with a hemostat.  The Cook evolution extractor was then attempted to be passed proximally.  It was necessary at this point to cut down on the common femoral vein and manually insert the device.  The sheath was able to be advanced into the vena cava.  The full length of it would barely reach the tip of the RV lead and ultimately traction and use of the sheath would not remove the lead.  It required placement of the evolution device right through into the actual tip of the device before it was delivered into the wound.  Unfortunately, we lost the sheath at this point and had to use a Bookwalter retractor to gain good exposure to the retroperitoneal, right common femoral, and iliac vein, and encircle it with a vascular Rummel tourniquet.  Once this was accomplished, the sheath was able to be grasped with a hemostat and delivered into the wound.  The opening into the vein was now repaired, which was quite large and responsible for a lot of the blood loss.  It was repaired with a bovine pericardial patch sutured in place with 5-0 Prolene suture.  The field was now completely hemostatic.  During this portion of the procedure, heparin had actually been administered and protamine was now administered to reverse this, and hemostasis appeared to be quite good.  Attention was then directed to the left infraclavicular area after changing gowns and gloves.  The common femoral vein was punctured ultimately as well as the 9.5 sheath and then the new ICD lead positioned on the 3rd attempt into a good position in the right ventricle.  This was secured in place with an active fixation device and tethered to the pectoral muscle with 2-0 Tevdek sutures.  The lead positioning was checked finally with fluoroscopy connected to the ICD generator.  He appeared to have a good positioning and placing the device in the pocket showed that there were excellent parameters, both sensing and pacing.  A rescue was not attempted at this point.  The pocket was thoroughly irrigated with antibiotic and even Betadine solution, then closed in layers with absorbable suture.  The subcutaneous pocket was closed.  The groin incision was then closed in layers with absorbable suture.  The patient appeared to be completely stable.  By fluoroscopy, there was no evidence of pneumothorax.


----------



## jewlz0879 (Aug 1, 2013)

I would go with 

33249
33244
33241
37197

I would use 33262 if the ONLY thing done was removing and replacing the ICD generator. Since a new RV lead was placed along with generator, you can code 33249 as this covers Insertion or _Replacement_ of permanent pacing ICD system with transvenous lead(s), single or dual chamber. 

HTH


----------



## willishm2012 (Aug 8, 2013)

Thank you for your help..


----------

