# angiogram performed during ICD implant



## gardnertel123 (Feb 4, 2010)

I have never seen an angiogram done during an ICD implant procedure before.
Here are the codes I selected for this procedure, however, encoderpro tells me to code a catheterization with the 93543.

33249, 33225, 33233, 71090, 93555, 93543

I could really use some help on this one.  
Thanks,
Terry

Procedure: Biv-Dual Chamber ICD Implantation, upgraded from dual chamber pacer (new RV ICD lead and LV lead, the old RV pacer lead was capped, the old atrial lead was connected to the new ICD generator). 

After positioning the patient and prepping and draping a sterile field, the region of the left deltopectoral groove was liberally infiltrated with local anesthetic agent. Following this, a 5 cm long transverse incision was made through the skin and subcutaneous tissue, exposing the pectoral fascia and muscle beneath. The pacer pocket was open and the pulse generator in the subcutaneous space was removed. The pocket was enlarged for the new ICD generator. Hemostasis was readily achieved with electrocautery. The axillary vein was punctured percutaneously and cannulated using the modified Seldinger technique, leaving a guidewire in place. Venous access were similarly obtained for the LV leads. A peel-away sheath was inserted over one the guidewire and the ventricular ICD lead (passive) was positioned in the RV apex using fluoroscopic guidance; satisfactory pacing thresholds and R waves were obtained as detailed below. The lead was secured in place at its entry to the vein. Then, a coronary sinus guiding sheath was maneuvered into the CS directly using a CS catheter as a guide for placement of a left ventricular epicardial venous pacing lead. *A balloon-occlusion CS angiogram was performed and a vein branch selected for lead placement. *A thin guidewire An LV pacing lead was advanced down this branch and the pacing lead advanced over the wire. Satisfactory pacing thresholds and R waves were obtained as below without diaphragmatic stimulation. The CS sheath was peeled and this lead was secured in place at its entry to the vein. Ten-volt pacing was used temporarily and assessment made for diaphragmatic stimulation; there was none. The previously-formed pocket was irrigated with antibiotic saline solution as was the rest of the incision. The old pacer lead was capped. The atrial lead was connected to the new ICD generator. After this, the new leads were connected securely to the pulse generator. The leads were wrapped carefully behind the generator, and the generator placed in the pocket. A sterile wand was placed over the device in its pocket and interrogation carried out. A securing suture was used to affix the generator to the subjacent tissue. Hemostasis was assured one last time and the pocket closed. The pectoral fascia was closed with 2-0 Vicryl® using a running mattress stitch. The subcutaneous and subcuticular layers were closed with 3-0 and 4-0 Vicryl® using a running stitch. Dermabond® was used for skin closure.


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## deeva456 (Feb 5, 2010)

Hi there!

I read the report and you cannot bill 93543 & 93555-26; the reason is highlighted in bold. The CS catheter is used as *A GUIDE* for placement of the LV epicardial venous lead. If it was medically necessary to perform an coronary angio @ the time of the ICD placement then yes bill 93543 but this is not indicated in the note. Reason to do a balloon -occlusion CS angio for other than selecting a vein branch to place a lead is not indicated. This is considered "road-mapping" or some will call it a "drive-by"   

I hope this makes sense, please let me know if you need more info.

Dolores, CCC-CPC


The lead was secured in place at its entry to the vein. Then, a coronary sinus guiding sheath was maneuvered into the CS directly *using a CS catheter as a guide for placement *of a left ventricular epicardial venous pacing lead. A balloon-occlusion CS angiogram was performed and a vein branch selected for lead placement. A thin guidewire An LV pacing lead was advanced down this branch and


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