# Aborted Afib Ablation



## leahlhaynie (Mar 4, 2015)

I could use some help on what would be proper to charge, please. Can I even charge 93656-53 if the physician didn't begin ablating? 


History: Patient with atrial fibrillation on Amiodarone and Multaq who presents for a PVI	

Pre-Op Diagnosis:  Atrial fibrillatio

Post-Op Diagnosis:  Same 

Procedure: 
1. Coronary sinus recording
3. Intracardiac echocardiography
4. Two transseptal punctures
5.  Central venous line placement


Access:
RFV1: 8F -> transseptal SL1 sheath -> Agilis sheath for ablation catheter
RFV2: 8F -> transseptal SL1 for Lasso Nav catheter
LFV1: 9F - ICE
LFV2: 7.5F - CS catheter


Procedure Summary/Findings: 
The risks, benefits, alternatives and anticipated results of EP study, sedation, ablation, and cardioversion were explained to the patient and family before the procedure.  Risks explained include cardiac tamponade, pneumothorax, bleeding, infection, vascular injury, heart block, MI, CVA, emergent sternotomy, intubation, death.  Written informed consent was obtained.  The patient was sedated by the anesthesia staff .  See  anesthesia records for full details.

PPM was reprogrammed to VVI 60- underlying atrial fibrillation with slow VR.

The area overlying the right and left groin was prepped and draped in the usual sterile fashion.  The above mentioned sheaths were placed in their respective locations using the modified Seldinger technique.  Ultrasound guidance was used to assist with access.  ICE catheter was inserted through the 11F venous sheath & advanced into the right atrium.  A decapolar catheter was inserted through the 8F venous sheath & placed in the coronary sinus.

8,000 units of IV heparin was then administered intravenously.  The 8F venous sheath was exchanged for an SL1 transseptal sheath and transseptal access was obtained in the standard fashion using the BRK1 needle with biplane fluoroscopy and ICE guidance. The SL1 was exchanged over a long wire for an  Agilis sheath.
The Biosense Webster ablation catheter was placed in the LA. Additional 10000 units was given. ACT was checked and it was 370seconds.
At this time on ICE there was an artifact noted on the tip of the Agilis catheter in the LA. After confirming in multiple view we removed the ablation catheter under ICE and noted no migration of the artifact. We then suctioned the Agilis catheter until the artifact was no longer seen. We then moved the Agilis into the RA. Using a long exchange wire the Agilis was taken out and a 9 Fr short sheath was placed. After Agilis was taken out there was a artifact (braiding) attached to the tip of the catheter. No clot was identified.

An ICE survey at the end showed no pericardial effusion.  Normal heart border was noted on fluoroscopy via LAO view.  .  The catheters were then removed from the body. The venous sheaths will be removed & hemostasis was achieved with manual pressure once ACT was < 170 s.  The patient tolerated the procedure well and was returned to a telemetry bed in stable condition. 
Clinical exam revealed no evidence of CVA or neurological deficit.

PPM was reprogrammed to MVP-R 60 and leads tested normal.

Opening LA pressure: 28 mmHg
Closing LA pressure: 28mmHg

Estimated Blood Loss: 10cc

Any Specimen Removed:  None

Complications:  None

Anesthesia:
General anesthesia (see anesthesiology note for exact medications/doses). 


Conclusion: 
1. Atrial Fibrillation on presentation
2. Artifact noted on Agilis sheath
3. ICE and transeptal puncture and aborted PVI.

Post-Procedure Plan:
1. Admit patient overnight as outpatient with extended recovery for continuous rhythm monitoring, careful assessment of intravascular fluid status.
2. Bedrest for 4 hours.
3. Resume cardiac diet.
4. Remove Foley catheter when mobilizing.
5. Anticoagulation: Pradaxa 150 mg PO  to start 6 hours after sheath removal provided hemostasis is secured.
6. Anti-arrhythmic agent: resume Multaq 400bid.
7. Plan for procedure -PVI in 3-4 weeks.


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## j.monday7814 (Mar 4, 2015)

I wouldn't bill it with a mod 53 either. maybe 93619, 93621, 93662, and 93462?


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## leahlhaynie (Mar 4, 2015)

j.monday7814 said:


> I wouldn't bill it with a mod 53 either. maybe 93619, 93621, 93662, and 93462?


That's the direction I'm leaning, but I'm not certain the dictation supports a full EP study. 

Thanks!


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## j.monday7814 (Mar 4, 2015)

When the new ablation codes first came out there was huge concern about reporting them when the physician doesn't perform a "comprehensive" EP study and I did watched a webinar from Jim Collins at Cardiology Coder and he said even if they don't do pacing/recording in RA, RV, and HIS then it is still proper coding to report the ablation. I don't remember if that logic also applies to the EP study or not. 

worst case you could completely break it down, he did the RA, but I don't see the RV or HIS


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