amym
Guest
Insurance bundled CPT 36556 into 93620. According to the NCCI edits they are bundled but are there any exceptions to the rule. I wanted to make sure before we write off the charge.
Procedure: History and physical exam were performed in the fasting
state and patient was brought to the electrophysiology
laboratory and the procedure indications and potential
complications, including, but not limited to, bleeding, deep venous
thrombosis, infection life-threatening cardiac tamponade, damage to
the conduction system necessitating pacemaker, aspiration and
advanced medication reaction and alternatives available were
explained to the patient. She appeared to understand and indicated
the same. An opportunity for questions was provided and informed
consent obtained. Under local anesthesia, the right femoral vein
was percutaneously cannulated using Seldinger technique, and one 7-
French and one 8-French sheath were introduced. Later in the case,
8-French sheath was exchanged over the wire for a small Agilis
steerable sheath for more support for the mapping catheter. A
deflectable Duo-Deca catheter was placed into the coronary sinus and
looped around the right atrium and was used for mapping, recording,
and pacing in the left and right atrium. The other sheath was used
to place an 8 mm large curve St. Jude Medical mapping and ablation
catheter in the right atrium. The patient's baseline rhythm at this
time was atrial flutter with a PCL of 250 msec. The flutter circuit
was mapped and the area of slow conduction was found to be in the TV-
IVC isthmus region. Atrial activation sequence was consistent with
counterclockwise right atrial flutter. Frame of mapping was
performed which confirmed the diagnosis. A temperature guided
mapping and ablation catheter was placed and presystolic atrial
activity was localized to the cava tricuspid isthmus in the CS
ostium and the inferior vena cava. A number of radiofrequency
ablations were applied in anatomic fashion to this area with
successful termination of atrial flutter during RF delivery. Post
ablation atrial flutter was not inducible with full atrial
stimulation protocol off and on Isuprel up to 2 mcg/minute.
Creation of bidirectional conduction block across the TV-IVC isthmus
area was demonstrated by pacing from the CS os and lower lateral
right atrium. At the end of the procedure, catheters and sheaths
were removed and hemostasis obtained.
Post ablation, the right atrial trans-isthmus conduction times were
as following:
1. Lateral to medial conduction time of 160 msec.
2. Medial to lateral conduction time 162 msec.
Before pulling the catheters, the mapping catheter was positioned at
his location and integrity of AV conduction was checked. AH was 80
msec and HV was 52 msec. Mapping catheter was advanced into the
right ventricular apex and pacing from the RV showed VA block cycle
length around 400 msec.
Complications: None.
Comment:
1. Successful flutter mapping and ablation with restriction of
sinus rhythm.
2. The patient will be restarted on anticoagulation with heparin
6 hours after the procedure and her Coumadin will be initiated
tonight. She will need at least 4 weeks of anticoagulation
with Coumadin.
Procedure: History and physical exam were performed in the fasting
state and patient was brought to the electrophysiology
laboratory and the procedure indications and potential
complications, including, but not limited to, bleeding, deep venous
thrombosis, infection life-threatening cardiac tamponade, damage to
the conduction system necessitating pacemaker, aspiration and
advanced medication reaction and alternatives available were
explained to the patient. She appeared to understand and indicated
the same. An opportunity for questions was provided and informed
consent obtained. Under local anesthesia, the right femoral vein
was percutaneously cannulated using Seldinger technique, and one 7-
French and one 8-French sheath were introduced. Later in the case,
8-French sheath was exchanged over the wire for a small Agilis
steerable sheath for more support for the mapping catheter. A
deflectable Duo-Deca catheter was placed into the coronary sinus and
looped around the right atrium and was used for mapping, recording,
and pacing in the left and right atrium. The other sheath was used
to place an 8 mm large curve St. Jude Medical mapping and ablation
catheter in the right atrium. The patient's baseline rhythm at this
time was atrial flutter with a PCL of 250 msec. The flutter circuit
was mapped and the area of slow conduction was found to be in the TV-
IVC isthmus region. Atrial activation sequence was consistent with
counterclockwise right atrial flutter. Frame of mapping was
performed which confirmed the diagnosis. A temperature guided
mapping and ablation catheter was placed and presystolic atrial
activity was localized to the cava tricuspid isthmus in the CS
ostium and the inferior vena cava. A number of radiofrequency
ablations were applied in anatomic fashion to this area with
successful termination of atrial flutter during RF delivery. Post
ablation atrial flutter was not inducible with full atrial
stimulation protocol off and on Isuprel up to 2 mcg/minute.
Creation of bidirectional conduction block across the TV-IVC isthmus
area was demonstrated by pacing from the CS os and lower lateral
right atrium. At the end of the procedure, catheters and sheaths
were removed and hemostasis obtained.
Post ablation, the right atrial trans-isthmus conduction times were
as following:
1. Lateral to medial conduction time of 160 msec.
2. Medial to lateral conduction time 162 msec.
Before pulling the catheters, the mapping catheter was positioned at
his location and integrity of AV conduction was checked. AH was 80
msec and HV was 52 msec. Mapping catheter was advanced into the
right ventricular apex and pacing from the RV showed VA block cycle
length around 400 msec.
Complications: None.
Comment:
1. Successful flutter mapping and ablation with restriction of
sinus rhythm.
2. The patient will be restarted on anticoagulation with heparin
6 hours after the procedure and her Coumadin will be initiated
tonight. She will need at least 4 weeks of anticoagulation
with Coumadin.