# LV lead revision?? Help please 33249 33233



## MELJNBBRB (Jul 3, 2014)

Pre-procedure Diagnoses 
  1. Acute on chronic systolic congestive heart failure [428.23, 428.0] 
  2. Ischemic cardiomyopathy [414.8] 
  3. LBBB (left bundle branch block) [426.3] 
  4. AF (atrial fibrillation) [427.31] 
  5. Pacemaker [V45.01] 


    Procedures 
  1. CARDIAC RESYNCHRONIZATION THERAPY DEFIBRILLATOR (CRT-D) [EP7704] 


    .
CARDIAC RESYNCHRONIZATION THERAPY PACEMAKER UPGRADE TO DEFIBRILLATOR (CRT-D) WITH LV LEAD REVISION 


Procedure:  
1. Upgrade of Cardiac Resynchronization Therapy - Pacemaker to Defibrillator (CRT-D) for primary prevention of sudden cardiac death
2. LV lead revision due to LV lead malfunction - diaphragmatic stimulation


Diagnosis: 


1. Ischmeic cardiomyopathy.


2. Chronic left ventricular systolic heart failure with EF 20-30% and >60% RV pacing in the setting of difficult to rate control AF, despite optimal tolerated pharmacological therapy, QRS > 130 ms, NYHA class III symptoms.


NEW SYSTEM: St Jude Medical CRT Defibrillator 


Sedation: IV Versed and Fentanyl 


Indication: Primary prevention of sudden cardiac death and treatment of symptomatic heart failure


 here for upgrade of CRT-P to ICD due to persistently low EF despite optimal tolerated pharmacological therapy and LV lead revision. She has a CRT-P with the LV lead turned off early after implant due to diaphragmatic stimulation. She states multiple attempts to re-program the device were made without success and she could not tolerate the diaphragmatic stimulation. In her last device interrogation she had more than 60% RV pacing, she has persistent atrial fibrillation; rate seems controlled most of the time with several episodes of rapid ventricular conduction.  
Per interrogation, symptoms are consistent with NYHA class III due to ischemic cardiomyopathy. She had an ablation in the past for PVCs per documentation and patient recollection. Denies bleeding other than skin ecchymosis due to warfarin use. No history of stroke or TIA. Off amiodarone due to fear of side effects and toxicity plus apparent lack of efficacy. Wonders about A fib ablation.

The patient gave written informed consent for CRT-D implant and understood risks, benefits and alternatives. 


Procedure Description: 


After informed consent was obtained, the patient was brought to the electrophysiology laboratory in the post-absorptive state. A time out was called and the patient was properly identified. The left infraclavicular area was prepped and draped in the usual sterile fashion. After local anesthetic infiltration with 1% lidocaine, an incision was made below the left clavicle. The incision was extended down to the capsule.The edge of the existing pacemaker was identified and the capsule opened with electrocautery. The CRT-P generator was removed from the pocket and the leads disconnected. In the Ring to RV coil configuration LV capture threshold was 2-3 V at 1.5 ms with no diaphragmatic stimulation evident at 10V @ 1.5 ms. The decision was made to use the existing LV lead in the extended bipolar configuration pacing through the proximal electrode. 


The capsule in the posterior, inferior and lateral aspect of the pacemaker pocket was opened with electrocautery and the pocket was expanded to accommodate the larger CRT-D generator.


Through the pocket, the axillary vein was entered at a single site and a guide wire was advanced into the right heart. A long introducer was advanced over the wire into the subclavian vein. 


Under fluoroscopic guidance, a right ventricular defibrillator lead was positioned in the right ventricular apex where the lead was actively fixed to the endocardium with the expandable/retractable screw. Good sensing and pacing parameters were confirmed. The axillary vein introducer was removed. After satisfactory sensing and pacing threshold were confirmed, the lead was fixed to the pectoralis muscle using the suture sleeve and nonresorbable 0 suture. The existing RV pacing lead was capped and fixed to the posterior aspect of the pocket. The pocket was irrigated with 300 ml of antibiotic containing saline solution and hemostasis was verified. 


The leads were correctly inserted and connected to the pre-programmed pulse generator. The leads and pulse generator were placed in the pre-pectoral pocket with the leads behind the device. Correct placement was confirmed with fluoroscopy. The pocket was then closed with 2 layers of absorbable 3-0 and a third layer of 4-0 suture was used to close the skin. Steri-strips were applied and the incision was covered with a sterile dressing. 


Device programmed VVIR 60-130 bpm with sleep rate 50 bpm; VT monitor zone 160-180, VT therapy zone 180-214 with ATP 3 bursts and 3 ramps and VF zone 214 and faster with extended detection to 24, 24 and 20 intervals.


Generator, leads and parameters were documented in a separate form scanned into the EHR.


Blood loss: 30 ml


IV dye total: 10 ml 


Findings: Successful upgrade of CRT-P to CRT-D with no acute complications. Pacemaker pocket revision.


Impression: Successful upgrade of CRT-P to CRT-D with no acute complications. Pacemaker pocket revision.


Recommendations:  
No driving x 2 weeks  
Follow up in pacer clinic in 2 weeks  
Keep incision dry x 4 days  
Avoid rising left arm above shoulder, pulling, pushing, lifting weight with left arm x 1 month  
IV antibiotics x 1-2 more doses  
PO antibiotics x 3 days  
Remove dressing at home  
CXR at am 


The patient will be kept overnight for observation for his safety, to complete further IV antibiotic prophylaxis, monitor for possible pneumothorax, heart perforation and lead dislodgement. The pacemaker will be interrogated and reprogrammed in the morning as required.


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## theresa.dix@tennova.com (Jul 14, 2014)

I would code this with 33249 and 33233. There is not a code for revision anymore. The wording was changed for codes 33222 and 33223 to relocation only.Oh and on this one if Medicare you might want to add the Q0 modifier for primary prevention. If not Medicare for get it.


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## kmuerth (Feb 6, 2015)

I code these all the time. First he removed PM GENERATOR, 33233, then he added the AICD DEFIB GENERATOR with a LV lead so automatically that's 33249. He also mentions testing of generator and thresholds so that is 93641,26 (if hosp setting)


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## kmuerth (Feb 6, 2015)

I mean RV lead was inserted with defib generator. wish the op report would show above when replying lol. Old RV lead was capped. and old LV lead was reused. nothing billable there.


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