# ICD Billing



## peeya (Jun 11, 2012)

Hi,

I am very new to Pacemaker/ICD placement billing, so can someone please help me with the coding of this procedure:

Operative report:  The patient was brought to the electrophysiology
laboratory.  Informed consent was obtained for the procedure.  The patient
was sedated by anesthesia.  The patient was monitored with ECG, external
pacemaker defibrillator, oxygen saturation, and noninvasive blood pressure
monitoring.  The patient was given IV antibiotics for prophylaxis prior to
skin incision.  The chest was prepped with chlorhexidine preparation.
Local anesthesia was obtained with 1% lidocaine.

Central venous cannulation was performed using 3 separate access wires
under fluoroscopic guidance using the axillary approach.  The location of
the guidewire in the right atrium was confirmed under fluoroscopy.  A 8-French, 
and
9.5-French sheaths was used.  The skin was incised with a #15 scalpel
blade.  Hemostasis was assured using electrocautery.  The deeper tissues
were dissected with a combination of electrocautery and blunt dissection.
At the level of the fascial plane, a pocket was formed.  The ventricular
lead was advanced to the RV apex.  Position at the RV apical septum was
confirmed under fluoroscopy.  Appropriate pacing characteristics were
obtained.  There was no evidence of diaphragmatic stimulation at
high-pacing output.  The lead was secured into position with 2-0 silk
nonabsorbable sutures.
Coronary sinus cannulation:  A 9.5-French sheath was utilized as the outer
sheath.  The long curved 9-French sheath was inserted through the outer
9.5-French sheath.  Cannulation of the coronary sinus was attempted with a
Glidewire but was unsuccessful.  Several different sheaths were used.
Ultimately a St. Jude CS catheter with a Luminaire CS finding tool was used
to cannulate the coronary sinus.  A balloon-tipped catheter was advanced
through the sheath and contrast injected into the coronary sinus.  The
balloon was inflated and coronary sinus angiogram was performed to define
the venous anatomy.
The LV pacing lead was placed through the sheath into the CS.  There was 1
lateral branch that was identified on venogram; however, the takeoff of the
lateral branch from the main CS body was very torturous.  Although on one
occasion we were able to cannulate the CS branch with the guidewire, the
left ventricular lead was unable to be advanced over the guidewire.
Despite extensive trials with multiple inner catheters and guidewires, we
were not able to place the lead in the lateral branch.

The atrial pacing lead was passed through the right atrial appendage and
the lead was screwed into position.  Pacing performed was evaluated.
High-output pacing did not cause frank stimulation.  The lead was secured
into place using 2 nonabsorbable sutures.  The left ventricular port of a
BiV ICD generator was plugged and ventricular and atrial leads were
attached to the generator.

Defibrillator testing:  The patient was induced into ventricular
fibrillation with high-frequency pacing.  A 25-joule defibrillation
corrected the VF to a baseline rhythm.

The pocket was flushed with antibiotic solution.  It was closed in layers
using 2-0 and 4-0 absorbable sutures.  The skin was closed with
subcuticular technique.
Steri-Strips were applied to the skin and a Bioclusive dressing was
applied.

Flouroscopy Time 61 minutes: Prolonged time was a result of difficult CS 
cannulation as well as turtuous anatomy requiring the use of multiple guide 
wires and sheaths.

In summary, this was a dual-chamber ICD placement with excellent
functioning and unsuccessful placement of left ventricular
pacing lead.

Should it be billed as 33249 & 33225-53..?


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## twizzle (Jun 12, 2012)

*ICD placement*

That is exactly how I would bill it, with the addition of 93641-26(P) for the testing at the end.


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## twizzle (Jun 12, 2012)

*ICD placement*

One other thing. What were the indications for the surgery?
You may need to add modifier Q0 to 33249 depending on DX's and insurance (applies to  Medicare only)


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## peeya (Jun 12, 2012)

wassock said:


> One other thing. What were the indications for the surgery?
> You may need to add modifier Q0 to 33249 depending on DX's and insurance (applies to  Medicare only)



Cardiomyopathy.. 

What is the indication that I need to look out for to add the Modifier Q0


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## twizzle (Jun 12, 2012)

*ICD billing*



peeya said:


> Cardiomyopathy..
> 
> What is the indication that I need to look out for to add the Modifier Q0


Cardiomyopathy and/or congestive heart failure. If the patient has an arrhythmia such as V tach and/or has had a previous cardiac arrest then the modifier does not apply.... it is purely for primary prevention of these dx's and is only for Medicare (not MCR replacement policies).


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