# Pacemaker Scenario



## em2177 (Mar 14, 2012)

33233, 33235, 33208??? Is this correct?  

REPROCEDURE DIAGNOSES:
1. Right atrial lead fracture.
2. Right ventricular lead fracture.
3. Complete heart block.
4. Sick sinus syndrome.

POSTPROCEDURE DIAGNOSES:
1. Successful implantation of new pacemaker on the left side.
2. Successful implantation of right atrial lead, St. Jude
   Medical.
3. Successful implantation of right ventricular lead, St. Jude
   Medical.

INDICATIONS:
The patient has an old pacemaker on the right side that has both the
right atrial and right ventricular lead, both fractured with
insulation breakage, ______ crushed versus oxidation of the leads.

DESCRIPTION OF PROCEDURE:
Methods, risks, and benefits were explained to the patient including
risk of death, MI, stroke, bleeding, infection. Patient was taken to
the EP lab in fasting state, prepped in usual sterile fashion.
Patient was allergic to IODINE, therefore IV Solu-Medrol and IV
Benadryl were given to the patient prior to the venogram.
Combination of sharp and blunt dissection created and opened up the
pacemaker pocket. Then, using the venogram, subclavian vein was
accessed. Thereafter, a 9-French sheath was placed in the subclavian
vein. Combination of curved and straight stylets were used to place
the RV lead into the RV apex. There were three leads already in the
heart, one in the atrial coming from the right side, two in the
ventricle coming from the right side. This was a new fourth lead
that was going into the right atrial apex or the septal location.
Appropriate thresholds and impedances were found. High-output
voltage did estimate the diaphragm. Thereafter, we switched out to a
7-French sheath and we placed in the right atrial appendage. Next,
an another right atrial lead that was already present there. We
found appropriate thresholds and impedances. High-output voltage did
estimate the diaphragm. Both of the leads were sutured down to the
chest wall. The pocket was flushed with antibiotic solution. Device
was also put in the pocket and was also sutured to the chest wall.
The pocket was flushed with antibiotic solution. Ancef powder was
applied to the pocket, and running 2-0 and 4-0 Monocryl was used to
close the pacemaker pocket. Dermabond was placed superficially.
Patient tolerated the procedure uneventfully. There was no
complications. Estimated blood loss less than 10 cc.

COMPLICATIONS:
None.

PACEMAKER DATA:
Patient has St. Jude Medical pulse generator 
Patient's right atrial lead
Patient's RV lead

LEAD MEASUREMENTS:
P waves are 1.8 millivolts, impedance was 631, thresholds 1.3 V at
0.5 msec. R waves 11.5 millivolts, impedance of 980 ohms, threshold
1.4 V at 0.5 msec. Patient will have stat chest x-ray and EKG. We
will observe overnight telemetry unit. Pacing parameters set at DDDR
60, max rate of 110.


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## theresa.dix@tennova.com (Mar 15, 2012)

This is a very confusing report. What I get out of this is 33208. I dont see anything else.


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## em2177 (Mar 15, 2012)

But the physician is removing an old pacemaker and leads and replacing both. Therefore, shouldnt 33233 be documented for removing the generator and 33235 for removing the leads? Then the 33208 for the replacement of generator and leads?

Thank You!


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## theresa.dix@tennova.com (Mar 15, 2012)

em2177 said:


> But the physician is removing an old pacemaker and leads and replacing both. Therefore, shouldnt 33233 be documented for removing the generator and 33235 for removing the leads? Then the 33208 for the replacement of generator and leads?
> 
> Thank You!




 There is no documentation that is telling me he removed the pacemaker generator or leads. Re read it and see if you can see anything I am missing, and truthfully it is hard to tell if he placed a NEW generator or not. Confusing. Maybe someone else can give some input here!

Remember if it isnt documented it wasnt done.


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## JudyW (Mar 15, 2012)

*questions*

I see no documentation to support the codes either.


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## kmuerth (Mar 21, 2013)

The op note is very poor. I see nothing to support a new pacemaker generator implantation, just that the old one was entered and a "new fourth lead" was added to a multi-lead pacemaker system. Ask the doctor? You could be losing out on revenue with this one. 

Karyn Muerth, CPC.


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