# Completely Stuck on this EP Study



## jtuominen (Apr 8, 2009)

Hi there-- This case has been challenging many of the coders in our department. I am about ready to send it back for addendum, but I thought I would post it to see if anyone else can make sense of what exactly was performed here. So far I have

93613
93652

And Im leaning towards 
93600
93603

I don't think it meets criteria for 93620 at all.

Please help!

PROCEDURES PERFORMED:
1.  EP study with induction of ventricular tachycardia.
2.  3D intracardiac mapping.
3.  Ablation of the left ventricular tachycardia.

INDICATION FOR PROCEDURE:  Patient is a 69-year-old white male 
with a history of coronary artery disease and severe LV dysfunction.  
He had a previous VT ablation which reduced the number of ICD shocks.  
However, over the recent few months, the patient started to have 
increasing frequency of ICD shocks from once a week to almost daily 
in the last few days.  He has been on antiarrhythmic drug therapy 
without success.  After the risks and benefits of the procedure were 
explained the patient consented for a repeat ablation.

PROCEDURE AND RESULTS:  After the written informed consent was 
obtained, the patient was transported to CV Lab 4 in the fasting 
state.  The procedure was performed under local anesthesia and 
sterile conditions.  IV Versed and fentanyl were used for conscious 
sedation.  By using the Seldinger technique, a 6 French quadripolar 
catheter was inserted through the right femoral vein and positioned 
into the *RV apex *for induction of VT.  The ESI balloon mapping 
catheter was inserted through the left femoral artery and positioned 
into the *left ventric*le.  The *ablation catheter was an 8 mm EPT that 
was inserted through the right femoral artery and positioned into the 
LV. * The patient received heparinization after the access of the 
femoral artery.

He was in sinus rhythm with first degree AV block and left bundle 
branch block at the baseline.  There were frequent PVCs of single 
morphology.  The PVC was mapped to the upper left ventricular septum.

The patient has a very large left ventricle which was beyond the 
mapping range of the balloon mapping catheter.  *The mapping and 
ablation was guided by the Array mapping system.  *The left ventricle 
geometry was collected by using the ablation catheter and the balloon 
mapping catheter.  *It was observed that extensive scar was present 
over the left ventricle.  The only viable myocardial area was the 
anterior lateral basal LV where the epicardial left ventricular 
pacing lead was placed.* 

The patient had multiple very wide QRS VTs with different rates in 
QRS morphologies.  The VTs were induced by triple ventricular 
extrastimuli and on one occasion by catheter manipulation.  None of 
the VT was pace terminable.  *The conventional mapping and balloon 
mapping both indicated origin of the VTs from the apical septal area 
near the border of the scar.* 

*Due to the unstable status of the VT the ablation was performed along 
the border of the scar. * *A linear lesion was created from the apical 
septum up to the anterior septum just below the level of the His 
bundle.  None of the ablations were applied in the healthy 
myocardium.  Furthermore, the ablation was extended in the 
anterolateral apical toward the apical septum.*  The PVC at baseline 
disappeared during the ablation procedure.  *Due to the close location 
of those PVCs to the His bundle region no ablation was applied to the 
basal left ventricular septum.

After the ablation of the left ventricular anterior septum, the 
patient had continued induction of VT of at least two types. * None of 
them was terminable by pacing but the rate seemed to be slowed down 
to about 170 beats per minute.

Due to the extensive scar tissue, low ejection fraction and the long 
procedure time it was decided to abort the ablation for concern of 
complications.

At the end of the procedure, the catheters and sheaths were removed 
and local pressure was applied to the puncture sites.  The pacing 
rate was increased to 80 beats per minute in order to suppress the 
PVC and hopefully will reduce the incidence of VT empirically.  
Otherwise, there was no complication.

For the short time being, sotalol will be continued at the same 
dosage. Mexiletine is discontinued because of the complaint of severe 
stomach upset.  If he improves clinically with ventricular arrhythmia 
the dosage of sotalol may be reduced.


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## deeva456 (Apr 9, 2009)

hello, 

I agree with the codes you have selected: 93600 93603 93652 & 93613. The doctor could have added modifier 22 to 93652 if he mentioned he accessed the left ventricle through transseptal puncture, assuming that is how he entered the left ventricle. 

good luck, this one was alittle tricky.

dolores


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