# Not normal pacemaker placement - help!



## hencked (Jun 30, 2011)

This is a not a  typical pacemaker insertion.  Below are the pertinent points to the op.

Patient is 2 days status post tricuspid bioprosthetic valve replacement and mitral valve annuloplasty.  She has had A-fib for years.  After surgery the temporary pacemaker was stopped, she had asystole due to complete heart block without an escape and is now absolutely pacemaker dependent.  Will place an epicardial LV pacing lead via the CS (coronary sinus).

Subclavicular incision made.  Left axillary vein was cannulated and guidewires advanced under flouroscopic guidance.  Leads passed via introducers.  Lead passed via axillary vein and positioned in the right atrail appendage.  Lead secured.  

A long sheath was passed over the EP catheter via the axillary vein into the coronary sinus.  Balloon tipped catheter was passed into the CS and a test injection performed to demonstrate an intraluminal position.  Balloon occlusion venography of the epicardial LV venous system was then performed and the lead was passed through the coronary sinus sheath and positioned under fluoro in an anterolateral LV vein.  Lead secured to pectoral fascia.  Pocket developed and pulse generator connected and seated.  


I am being told the lead placed in the left ventricle is now pacing the right ventricle also...still kind of a dual pacemaker is what pacemaker lab is saying.  I know that one lead is in the right atrium (33206) and the right ventricle is pacing via the Left venous system with the lead in the left ventricle (+33225).  Obviously 71090 for the flouro, or should it be billed as a dual pacemaker 33208 and 33225, 71090.  I know the lead is not in the right ventricle, so that is why I'm thinking 33208 isn't correct, but not sure.  Please help.....I am confused.

Thanks,

dlh


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## theresa.dix@tennova.com (Jul 1, 2011)

hencked said:


> This is a not a  typical pacemaker insertion.  Below are the pertinent points to the op.
> 
> Patient is 2 days status post tricuspid bioprosthetic valve replacement and mitral valve annuloplasty.  She has had A-fib for years.  After surgery the temporary pacemaker was stopped, she had asystole due to complete heart block without an escape and is now absolutely pacemaker dependent.  Will place an epicardial LV pacing lead via the CS (coronary sinus).
> 
> ...




Well it looks to me we have a RA lead and a LV lead. 33206-33225-71090


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## hencked (Jul 1, 2011)

*Thanks for the help!*

Logically that is what I thought was correct, to code where the leads were placed. 

Thanks for the help!  

hencked


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