# Bi-vent lead extraction and implantation of new lv lead



## ksschroeder (Dec 28, 2010)

Good Morning,  I am wondering if I coded this note correctly:

INDICATIONS: A 66 year old man with history of severe cardiomyopathy and congestive heart failure.  He underwent the implantation of a cardiac resynchronization defibrillator on 5/14/2010 (current dos is 9/21/2010, so is past 90 day global period). Recently he demonstrated a dislodgement of the coronary sinus lead.  The initial coronary sinus lead was placed with some difficulty in the lateral vein, but due to a very unstable position an angioplasty wire was left protruding from the tip of the vein.

DESCRIPTION OF PROCEDURE: The patient was brought to the electrophysiology lab in a fasting state.  He was prepped and draped in the usual sterile manner over the anterior chest.  Local anesthesia was performed in the left subclavicular fossa where the old device is located and then an incision was made on top of the old scar.  The incision was extended through the fibrous capsule.  The device and leads were exposed and dissected free.  Subsequently, the left ventricular lead was visualized under fluoroscopy and it appeared that it had come back a couple of centemeters from the original location in the high lateral vein.  Initially the wire from the inner lumen of the left ventricular lead was pulled, but it had fractured and there was a small remnant of wire distally in the lateral vein.  The wire was then explanted by gentle retraction.

Access was obtained in the left axillary vein, and a wire was attempted to be advanced.  However, it could not be advanced beyond the level of the clavicle.  Contrast was injected through the needle and it demonstrated a 95% stenosis of the left subclavian vein beyond the clavicular level.  With some difficulty, an angioplasty wire was then advanced and it could cross the stenosis.  Multiple attempts were made to advance several dilators but this failed.  Subsequently, a dilator was advanced just proximal to the stenosis, and through it a Magic Torque wire was advanced and could cross the stenosis.  Over it a 7-french and then an 8-french sheath were advanced beyond the stenosis with great difficulty.  Angiograms demonstrated patency of the vein distal to the stenosis.  Through the 8-french sheath, a Super Stiff 300 cm wire was advanced.  Over the wire a long 9-french safe sheath was advanced all the way to the superior vena cava.  Through this, a Guidant CSEH catheter was advanced and positioned at the level of the coronary sinus os.   A small amount of contrast was injeted to prove the orientation of the catheter tip.  An angioplasty wire (whisper view) 14,000 was advanced distal in the cor onary sinus.  A coronary sinus angiogram was then performed by injecting contrast through the sheath and this demonstrated a very large posterolateral branch with only 2 distal branches.  Then a middle cardiac vein that anastomosed to the anterior cardiac vein and an anterior cardiac vein which is large.

Usin a Rapido IC 90 degree at the posterolateral vein was selectively cannulated and an angioplasty wire was advanced distal in to the vein.  A new left ventricular lead which is a St. Jude medical 1056P86cm serial # XXXXXXX lead was advanced and positioned distal in to the vein.  The lead was tested in different configurations.  There was phrenic nerve capture at a couple of the sites, however, in the final position phrenic nerve capture could not be demonstrated when pacing from the ring electrode.  The face sheath was removed and then  the guide was cut.  During this time fluoroscopy was performed and demonstrated a very stable lead position.  The lead was attached to the deep fascia using 0 Ethibond.  The pocket was irrigated with clindamycin solution since the patient is penicillin and vancomycin allergic.

The 3 leads were then reattached to the pulse generator which was reimplanted in the pocket.  The wound was closed in three layers using 3-0 and 4-0 Vicryl.

At the end of hte procedure, sponge count was correct.  There were no complications.  The explanted left ventricular lead is a St. Jude medical 4592, serial # XXXXXX implanted on 5/14/2010.

IMPRESSION AND PLAN: 
1. Successful explantation of dislodged left ventricular lead.
2. Left subclavian vein stenosis and peripheral venography.
3. New left ventricular lead placement.
4. DFT were tested after T-wave shock which induced ventricular fibrillation and defibrillation threshold was less than 17 joules.

PLAN: The patient will be followed overnight and then discharged in the morning.


We billed: 33244, 93641-26, 33224 and 71090-26 to a Medicare Replacement Plan and 33224 was denied as N19 (Incidental to primary procedure).  Medicare does not bundle any of these codes and the patient was no longer in any global period at this time of service.   
Before I send an appeal, I would like to have someone else take a look and see if I selected the most appropriate codes for this procedure first.  
Thank you in advance for taking the time to review this rather long op note and providing your input...


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## theresa.dix@tennova.com (Dec 29, 2010)

kcassidy said:


> Good Morning,  I am wondering if I coded this note correctly:
> 
> INDICATIONS: A 66 year old man with history of severe cardiomyopathy and congestive heart failure.  He underwent the implantation of a cardiac resynchronization defibrillator on 5/14/2010 (current dos is 9/21/2010, so is past 90 day global period). Recently he demonstrated a dislodgement of the coronary sinus lead.  The initial coronary sinus lead was placed with some difficulty in the lateral vein, but due to a very unstable position an angioplasty wire was left protruding from the tip of the vein.
> 
> ...




Yes I think you have coded this correctly. I cannot see why this was denied. The only thing i can pick out is that there is really not a code that aaccuratly describes Left V lead extraction so some might tell you to choose 33999 cpt unlisted code, altho i know plenty that use 33224. Maybe this particular replacement plan wants you to use 59 modifier?


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## ksschroeder (Dec 30, 2010)

Thanks for your reply.  That is what I was thinking too.  

I did do more research and found a CPT Assist from July 2000 that says in part:  The leads, including suture ties, are freed from the capsule. The generator is disconnected from the leads and removed from the pocket. The leads are cut to expose their inner cores, and are then sized to accept the locking stilette which is passed through the inner core of the lead to its distal end where it is engaged under gentle traction. A firm plastic sheath is passed over the stilette and lead, freeing the lead from intravascular adhesions as it is advanced toward the lead's distal end. Firm traction is applied to the locking stilette while counter traction is applied to the endocardial surface with the plastic sheath. This process is repeated for the second (and possibly a third) transvenous lead as part of the pacing cardioverter-defibrillator system (code 33244).

The coder's desk reference also says under CPT 33244:  "A new wire may be placed, but is reported separately."

So it does look like AMA's intent may be to use 33244 for the extraction of the third LV lead even though it is not in the official description of the code.  But then of course, I could be interpreting it completely different than it was intended too.  

I do appreciate your input.  Is really good to get anothers point of view and sometimes just reassurance.


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## theresa.dix@tennova.com (Dec 30, 2010)

kcassidy said:


> Thanks for your reply.  That is what I was thinking too.
> 
> I did do more research and found a CPT Assist from July 2000 that says in part:  The leads, including suture ties, are freed from the capsule. The generator is disconnected from the leads and removed from the pocket. The leads are cut to expose their inner cores, and are then sized to accept the locking stilette which is passed through the inner core of the lead to its distal end where it is engaged under gentle traction. A firm plastic sheath is passed over the stilette and lead, freeing the lead from intravascular adhesions as it is advanced toward the lead's distal end. Firm traction is applied to the locking stilette while counter traction is applied to the endocardial surface with the plastic sheath. This process is repeated for the second (and possibly a third) transvenous lead as part of the pacing cardioverter-defibrillator system (code 33244).
> 
> ...





Yes AMA tells us to use 33244 for lv lead extraction some other sources ie Jim Collins tells us to use unlisted so I think either way is ok.


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