# Right ventricular Tandem Heart placement???



## csorensen21@yahoo.com (Apr 29, 2015)

I have never billed this before or had this sort of catherization hit my desk. I was looking up several different codes in regards to the Tandem Heart placement such as 33990-33993. Can someone help me here?

Procedure:
1. Left Heart Catheterization
2. Right ventricular TandemHeart placement via right internal jugular vein under ultrasound monitoring
3. Left femoral artery axis for Impella implantion 3.5 ultrasound monitoring

The procedure in detail was discussed with the family and they fully understood that this procedure is a salvage procedure in attempt to support this patient with his advanced cardiomyopathy and what appears to be acute myocarditis and severe cardiogenic shock, evident with significant end organ damage. Family were aware of the procedure, risks of bleeding that could be excessive due to his liver insufficiency, risk of worsening renal insufficiency due to reuse of contrast, risks of death, risk of arrhythmia all were fully explained to the family and all their questions were answered. Patient was prepped according to protocol. Initially we obtained access from radial artery 5-french sheath was placed and then we attempted to engage a thick catheter without good success, so we use the judkins right and a judkins left catheters. The judkins right was advanced across the aortic valve, performed pressure measurements, and a pullback was performed and then engaged with the right coronary artery. Judkins left catheter was used to engage with the left coronary system and geographic images were performed. Then subsequently access was obtained from the right internal jugular vein, and an 8 French sheath was initially advanced. Then multiple dilators were used and with an extra support wire to obtain a good access into the right internal jugular vein and deployment of the right ventricular Tandem heart was advanced under fluoroscopic monitoring and deployed into the right atrium and proper deairing technique was used to connect the catheter this without any immediate complication of problem. Then, subsequently access from the left femoral artery using 4-french sheath and then subsequently we used an extra support wire and upgraded the sheath and dilated the leg and obtained 8-french access, Perclose devices were deployed, two of them, in the left femoral artery in preparation for withdrawl of the impella catheter and to facilitate closure of the entry incision. Meanwhile, the sutures were secured and no immediate problems were noted. Pigtail catheter was advanced across the aortic valve, and then an extra support wire was deployed into the LV and over that extra support the Impella catheter was advanced without any immediate problems and careful fluoroscopic monitor was done. Then, subsequently the decision was made to hold on intraaortic balloon pump as the patients INR was 28 and especially with his Impella catheter, he was still not generating good carotid output and blood pressure was still in the low level. Patient wsa maintained on pressures through the whole duration and was transported safely back to his room.


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## j.monday7814 (Apr 29, 2015)

It looks like you're supposed to use 33991-33993, but I don't see where he mentioned that a transeptal puncture was performed. Maybe it was done and it just needs to be documented or if it wasn't done then maybe a modifier 52.


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## csorensen21@yahoo.com (Apr 29, 2015)

j.monday7814 said:


> It looks like you're supposed to use 33991-33993, but I don't see where he mentioned that a transeptal puncture was performed. Maybe it was done and it just needs to be documented or if it wasn't done then maybe a modifier 52.



My question is can I bill the heart cath with the tandem heart cath code and yes that was done an addendum was added later to note that per the physician.


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## j.monday7814 (Apr 29, 2015)

> patient with his advanced cardiomyopathy and what appears to be acute myocarditis and severe cardiogenic shock, evident with significant end organ damage.



as far as NCCI edits are concerned you can easily bill both of those together, but based on the part of the report that I quoted I don't think there is any medical necessity to support a diagnostic cath. it looked more like the catheter placement in the LV and coronaries was part of road-mapping prior to deployment. is this the full report or did he provide findings of the LV pressure, pullback gradient, coronary anatomy, etc?


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## csorensen21@yahoo.com (Apr 30, 2015)

j.monday7814 said:


> as far as NCCI edits are concerned you can easily bill both of those together, but based on the part of the report that I quoted I don't think there is any medical necessity to support a diagnostic cath. it looked more like the catheter placement in the LV and coronaries was part of road-mapping prior to deployment. is this the full report or did he provide findings of the LV pressure, pullback gradient, coronary anatomy, etc?



This is the whole op note. That is all that he has given me on this. Can I bill for ultrasound as well? I'm confused on this whole report to be honest.


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