# Pacemaker - Just received a denial from Medicare



## Jess1125 (Jul 18, 2014)

Just received a denial from Medicare for the following procedure and just want to make sure this was coded correctly as I'm pretty sure it is but I'm throwing this out there anyway! 

PROCEDURES PERFORMED:
1.  Placement of a single chamber pacemaker.
2.  Relocation of a pacemaker pocket.
3.  Removal of pacemaker pulse generator.


PREOPERATIVE DIAGNOSES:
1.  Symptomatic bradycardia.
2.  Permanent atrial flutter.
3.  Dual-chamber pacemaker in situ.
4.  RV lead failure with intermittent loss of capture.


POSTOPERATIVE DIAGNOSES:  
1.  Symptomatic bradycardia.
2.  Permanent atrial flutter.
3.  Dual-chamber pacemaker in situ.
4.  RV lead failure with intermittent loss of capture.  
5.  Right subclavian venous occlusion.


ANESTHESIA:  Local Lidocaine and moderate sedation with intravenous Versed and Fentanyl.


SPECIMENS:  The prior pulse generator.


ESTIMATED BLOOD LOSS:  100 mL.


COMPLICATIONS:  None.


INDICATIONS FOR SURGERY:  The patient is a 77-year-old woman with a history of a dual-chamber pacemaker, generally with ventricular pacing dependence and permanent atrial flutter.  She does not tolerate full anticoagulation.  She has had noted increase subacutely of her pacing threshold, with intermittent dramatic rises in the threshold values.  Last week she had an episode of syncope and found to have heart rates in the 30s.  She was noted to have an acute increase in her pacing threshold.  Given her pacing dependence with symptomatic bradycardia, with unreliable RV lead, she is referred for RV lead revision.


DESCRIPTION OF PROCEDURE:  The indications, risks, benefits, alternatives, and details of the procedure were discussed with the patient, and she provided informed written consent.  The patient was brought to the electrophysiology laboratory where she was prepped and draped in the usual sterile fashion.  Right upper extremity venography demonstrated an occluded right subclavian system around the leads.  There was ample collateralization suggestive of a chronic occlusion.


We then proceeded as per our preoperative discussions to place to a left-sided system.  As she is in permanent atrial flutter, a single chamber device was placed.  Left upper extremity venography confirmed a patent left subclavian system.


Lidocaine 2% was used to anesthetize the left pectoral region.  Using a scalpel, a 4 cm incision was made over the left deltopectoral groove.  Using blunt dissection and brief bursts of electrocautery, a device pocket was developed superficial to the pectoralis fascia.


Using the venogram as a guide, left subclavian venous access was obtained with an introducer needle and a wire placed.  A 7-French sheath was placed.  The RV lead was delivered to the RV apical septum under fluoroscopic guidance.  There was ample space between the lead and the prior pacing lead.  The active fixation mechanism was deployed. Appropriate sensing, threshold, and impedance values were obtained.  The sheath was split and removed.  The lead was secured to the underlying tissue with 0 silk x2.


Hemostasis was ensured in the pocket with further electrocautery.  The pocket was irrigated with copious Bacitracin and saline solution.  The pulse generator was connected to the leads with the appropriate torque wrench.  The device and lead assembly were then placed in the cleaned pocket.  The pulse generator was secured to the underlying tissue with 0 silk x1.


The pocket was closed in 3 layers with 2-0, 3-0, and 4-0 suture material.  Steri-Strips and a Tegaderm dressing as well as a pressure dressing were applied.


Attention was then turned to the right-sided pocket.  To avoid future cross inhibition with the new pacemaker, the pulse generator was removed.  Lidocaine was used to anesthetize the right deltopectoral groove.  Using a scalpel, an incision was made over the implantation site.  Using blunt dissection and brief bursts of electrocautery, the pocket was opened and the device and leads were freed from their adhesions.  Using the appropriate torque wrench, the pulse generator was removed from the leads and removed from the field.  The RV lead was tested and found to be intact with variable pacing threshold, but no noise on the lead and no impedance issues in the bipolar or unipolar modes.


Hemostasis was ensured in that pocket with further electrocautery.  The pocket was irrigated with copious Bacitracin and saline solution.  End caps were applied to both leads and secured with 0 silk x2 each.


The pocket was closed in 3 layers with 2-0, 3-0, and 4-0 absorbable suture material.  Steri-Strips and a Tegaderm dressing as well as a pressure dressing were applied.


The patient tolerated procedure well, and was transferred to a monitored bed in stable condition.


IMPLANTED HARDWARE:  The pulse generator is a Medtronic SESR01, serial number NWR264336 H.  The RV lead is a Medtronic 5076, serial number PJN3369234.  The explanted pulse generator is a Medtronic ADDRS1, serial number NWA217430 H from 4/17/12.  The capped A lead is a Medtronic 4592, serial number LER188260 V from 4/17/12.  The capped RV lead is a Medtronic 4092, serial number LEP458493 V from 4/17/12.


LEAD PARAMETERS:  The RV lead senses paced R waves of 4.1 millivolts, threshold 0.5 volts at 0.5 milliseconds, impedance 838 ohms.


The device is programmed VVIR 60-120.

What got coded was 33207 and 33233. The 33207 got denied for medical necessity not met. (Probably due to the lovely new NCD for pacemakers...)

The patient has documented symptomatic bradycardia. Obviously I didn't use the sinus node dysfunction or 2nd/3rd degree heart block. Not documented anywhere that the bradycardia was irreversible so I didn't have the KX modifier on as well. 

I find this ridiculous. This patient had an RV lead that wasn't working right.  A new RV lead was placed along with a generator but medical necessity wasn't met!!!???

I thought maybe I could link the RV lead failure dx to the 33207 (it was just linked to the 33233) but it still wouldn't meet their qualifications for medical necessity based on the new NCD...

Jessica CPC, CCC




The patient tolerated the procedure well.


----------



## theresa.dix@tennova.com (Jul 24, 2014)

Jess1125 said:


> Just received a denial from Medicare for the following procedure and just want to make sure this was coded correctly as I'm pretty sure it is but I'm throwing this out there anyway!
> 
> PROCEDURES PERFORMED:
> 1.  Placement of a single chamber pacemaker.
> ...



Wow! Jessica maybe you should try v53.31( fitting and adjustment of pacemaker)  I wonder if that is going to work since its not listed on the NCD. I hope it will. So now that I thought about it try V53.31 with the occluded subclavian second. That is what I would try and appeal with records.


----------

