amym
Guest
How would I bill an attempt at a Bi-V implant, CPT 33249, 33225?
After sterile preparation of the skin surrounding the
left deltopectoral area with antiseptic scrub, this area was
carefully covered with a Steri-Drape followed by the application of
sterile towels and a sterile laparotomy sheet. Local anesthesia
with 1% lidocaine was administered and an approximately 2 inch
incision across the left deltopectoral groove was made. Using blunt
dissection with careful hemostasis, the left cephalic vein was
isolated. However, it was deemed to be inadequate to accommodate
the lead. Under the guidance of fluoroscopy and the left upper
extremity venogram, the left axillary vein was accessed and a
guidewire was inserted. However, it was noted that the guidewire
would not advance into the superior vena cava and it would make the
turn into a stent which was implanted in the right subclavian vein.
Fluoroscopically, the stents seemed to be too lateral to be
encroaching on the superior vena cava. However, multiple attempts
at crossing the wire would not stay away from the stent. At this
time, a selective venogram with 7-French sheath in the left axillary
vein was performed, which showed that the stent was coming out of
the right subclavian vein and blocking the entrance into the
superior vena cava. This meant that there was no way to advance any
wire or lead into this superior vena cava without having to cross
the straps of the statin. Given the fact that the patient is on
dialysis and using the right upper extremity AV fistula, the
decision was made to abort and not proceed with implant. Implants
could have jeopardized the stent, putting the patient at risk for
superior vena cava syndrome, jeopardizing the right-sided AV fistula
as well as having an increased risk of lead fracture from the
mechanical rubbing and pressure from the stent strap on the leads.
At this time, the sheath and wire were removed and proper hemostasis
was achieved and incision was closed in 3 different layers with
absorbable sutures. A sterile occlusive dressing was applied and a
pressure dressing was applied on top of that and the patient was
transferred back to monitoring area in stable condition.
Comments: Attempt at CRT/D implant was aborted secondary to the
right subclavian stent encroaching on superior vena cava ostium.
After sterile preparation of the skin surrounding the
left deltopectoral area with antiseptic scrub, this area was
carefully covered with a Steri-Drape followed by the application of
sterile towels and a sterile laparotomy sheet. Local anesthesia
with 1% lidocaine was administered and an approximately 2 inch
incision across the left deltopectoral groove was made. Using blunt
dissection with careful hemostasis, the left cephalic vein was
isolated. However, it was deemed to be inadequate to accommodate
the lead. Under the guidance of fluoroscopy and the left upper
extremity venogram, the left axillary vein was accessed and a
guidewire was inserted. However, it was noted that the guidewire
would not advance into the superior vena cava and it would make the
turn into a stent which was implanted in the right subclavian vein.
Fluoroscopically, the stents seemed to be too lateral to be
encroaching on the superior vena cava. However, multiple attempts
at crossing the wire would not stay away from the stent. At this
time, a selective venogram with 7-French sheath in the left axillary
vein was performed, which showed that the stent was coming out of
the right subclavian vein and blocking the entrance into the
superior vena cava. This meant that there was no way to advance any
wire or lead into this superior vena cava without having to cross
the straps of the statin. Given the fact that the patient is on
dialysis and using the right upper extremity AV fistula, the
decision was made to abort and not proceed with implant. Implants
could have jeopardized the stent, putting the patient at risk for
superior vena cava syndrome, jeopardizing the right-sided AV fistula
as well as having an increased risk of lead fracture from the
mechanical rubbing and pressure from the stent strap on the leads.
At this time, the sheath and wire were removed and proper hemostasis
was achieved and incision was closed in 3 different layers with
absorbable sutures. A sterile occlusive dressing was applied and a
pressure dressing was applied on top of that and the patient was
transferred back to monitoring area in stable condition.
Comments: Attempt at CRT/D implant was aborted secondary to the
right subclavian stent encroaching on superior vena cava ostium.
