# EP help



## schmsuz (Apr 8, 2011)

Could someone please help with the diagnostic EP portion of this report?  If you could also let me know the rationale, that would be great!!

PROCEDURE NOTE:
Informed consent was obtained.  The patient was brought to the EP laboratory in a
fasting state.  The groin area was then prepped and draped in the usual sterile
fashion.  1% Xylocaine was used for local anesthetic.  Modified Seldinger technique
was used to access the bilateral femoral veins to allow for insertion of 3 venous
sheaths.  A deflectable Decapolar catheter was then introduced and was used to
cannulate the coronary sinus.  According to the coronary sinus activities activation
mapping, it appeared to be right-sided atrial tachycardia.  The mapping/ablating
catheter was then introduced into the right atrium using a supporting DAIG SL2
curved sheath.  The catheter was a Biosense, thermo-cooled catheter.  Mapping was
then performed.  According to the mapping data, it appeared to be counterclockwise
atrial flutter rotation.  Pacing at the right atrial isthmus region indicated that
it was within the atrial flutter circuit.  Ablation was then performed.  Several
applications were delivered along the isthmus.  During the process of creating an
ablation line along the isthmus, it was noted that the activation of the atrial
tachycardia/flutter changed with the earliest activation appearing to be equal in
all the CS leads.  After completion of the isthmus line, mapping was then
reperformed.  Now the activation sequence has changed and it appeared to be coming
from the left atrium.

An intracardiac echocardiogram catheter was then introduced into the right atrium. 
It was a Biosense bowel sounds catheter.  Using the Cartosound 3-D mapping system,
the left atrial shell was then reconstructed.  Subsequent, transseptal
catheterization was then performed using a Preface sheath under the guidance of ICE,
hemodynamics and fluoroscopy without any complications.  Heparin bolus and heparin
drip were then given and adjusted during the procedure to maintain ACT about 250-300
seconds range.  The ablating catheter was then introduced into the left atrium and
detailed mapping was then performed.

Using entrainment mapping coupled with activation mapping data, there appeared to be
focal atrial tachycardia located at the mitral annulus region near the base of the
left atrial appendage.  Several applications were delivered at this site, along the
annulus, and toward the base of the left atrial appendage, with power titrated up to
40 watts.  Despite good mapping data, the atrial tachycardia persisted.  After about
40 applications, remapping was then performed.  Using activation mapping data
coupled to entrainment mapping data, it appeared to be reentrant circuits around the
mitral annulus.  It should be noted earlier that macro reentrant circuits along the
left atrial roof was quickly ruled out by activation mapping data.

The mitral isthmus was then ablated.  The catheter was initially brought toward the
ventricular side of the mitral annulus and clockwise rotation toward the left
inferior pulmonary vein.  The power was titrated up to 40 watts and at this
location, spot application was delivered at each site lasted for about 30 seconds
each.  Despite establishment of a good mitral isthmus line, the atrial tachycardia
persisted.  There appeared to be good atrial signal in the coronary sinus region. 
Therefore, the patient was cardioverted to sinus rhythm with 100 joules. 
Differential pacing was performed indicating there was still conduction across the
mitral isthmus.  The ablating catheter was then withdrawn from the left atrium and
introduced into the coronary sinus where good atrial signal was obtained at the mid
coronary sinus region corresponding to the mitral isthmus ablation line. 
Applications were delivered at this site with power titrated up to 20 watts. 
Proximal coronary sinus pacing was performed during the application to document
local conduction block.  About 10 applications were delivered within the coronary
sinus.  Subsequently, the ablating catheter was then reintroduced into the left
atrium and differential coronary sinus pacing was then performed.  There was still
conduction across the mitral isthmus and therefore several more application were
delivered along the mitral isthmus with power titrated up to 40 watts.  Coronary
sinus pacing was performed during RF applications to document conduction block. 
Eventually, after several applications, we were able to document local conduction
block.  Differential pacing was then performed with evidence of conduction block
across the mitral isthmus region with the conduction time of about 110 milliseconds
as opposed to 20 milliseconds prior to the mitral isthmus ablation.  A total of 115
RF applications were delivered during procedure with a total application time of
3945 seconds.  After achievement of mitral isthmus block, the intracardiac
echocardiogram was then performed to look for pericardial effusion.  There was no
evidence of pericardial fluid present.  At this point, all the catheters and sheaths
were then removed once the ACT was less than 180 seconds.  The patient tolerated the
procedure well and there were no apparent complications.


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## rpcarrillo (Apr 12, 2011)

The dictation style is not what I'm used to, but I'll take a crack at it. The codes I was able to divine were:

93651
93620
93621
93462
93662
93613

Resist the temptation to code 92960 for the cardioversion in this instance since it appears to be aimed at the arrhythmia that was induced during the procedure.

Also, the mention of the "Biosense bowel sounds catheter" has to be one of the most amusing transcription errors I've seen in a while.

Hope this helps.


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## schmsuz (Apr 13, 2011)

Thanks for your help!  Why is 93620 able to be billed?  It is my understanding that RA, RV pacing/recording and His bundle recording needs to be done in order to bill a comprehensive study.  Is that not correct?


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## mariecass (Apr 13, 2011)

I read your report, but I wouldn't bill the 93620 based off this report only because the actual pacing of each area and recording isn't mentioned. My Dr's state those specific areas as paced and recorded in their reports. If they don't mention it, I send it back to be reviewed and have an addendum added if needed before its billed out. 

Thanks
Cassidy


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## schmsuz (Apr 13, 2011)

Thanks....thats what I was thinking with this report but wasn't quite sure.  This can be very confusing.  Thanks for your help!!


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## mariecass (Apr 13, 2011)

Good Luck and you are welcome!


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