Hello, Please help with coding "tunneling across the chest to the existing device." I am new to Cardiology coding; Would it be a code from general surgery or complex procedure, so modifier 22 only? my other option would be a tunneled central line insertion - 36558? Any feedback are greatly appreciated.
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki Inserion new RT ventr lead on RT and tunnelling across the chest to exist device
- Thread starter VelshAS
- Start date
twizzle
Guest
RV lead to existing device
Without some more detail it's almost impossible to code this. However, if I'm understanding correctly, the provider inserted a new RV lead and tunneled it through the subcutaneous tissue and attached it to a device, PPM or ICD on the left. Nothing else. Any generator replacement, lead removal?
If so, 33216. You can't just add modifier 22 unless the dictation supports a particularly difficult/time-consuming procedure. It's not general surgery, it's a cardiovascular procedure. It's not a central line so 36558 is incorrect.
33216 only.
Without some more detail it's almost impossible to code this. However, if I'm understanding correctly, the provider inserted a new RV lead and tunneled it through the subcutaneous tissue and attached it to a device, PPM or ICD on the left. Nothing else. Any generator replacement, lead removal?
If so, 33216. You can't just add modifier 22 unless the dictation supports a particularly difficult/time-consuming procedure. It's not general surgery, it's a cardiovascular procedure. It's not a central line so 36558 is incorrect.
33216 only.
Thank you for the feedback. Here is the part of the report. Yes, I do agree on 33216 and mod 22 - it is not usual place to insert leads.
PROCEDURE: Insertion of new right ventricular lead on the right side and tunneling across the chest to the existing pocket/device on the left side.
INDICATIONS: A ---female with a pacemaker in place for sinus bradycardia and paroxysmal AV block. Her device was initially implanted in 2014. She showed progressive increase in pacing threshold in the right ventricular lead over the past few months. We monitored carefully until it became clear that the lead will become dysfunctional. Her most recent pacing threshold was 4.25 volts at 1.5 milliseconds today. She comes in for insertion of a new lead.
The patient has end-stage renal disease and is on dialysis. She has a fistula on the left side. This is the same side where her original device is placed. I communicated with her surgeon who was concerned about inserting an additional lead in that area and requested that we go on the other side. For this reason, I plan to place the lead on the right side and tunnel it across the chest to the existing pocket/pacemaker.
PROCEDURE DESCRIPTION: The patient presented in the fasting state. Anesthesia was induced and maintained by anesthesiologist. The chest area was prepped and draped in the usual sterile fashion. An incision was made beneath the clavicle on the right side. Utilizing cautery, the incision was extended to the level of the pectoral fascia. Under fluoroscopy guidance, access into the right axillary vein was obtained and a 7-French sheath was inserted. The RV lead was inserted and actively fixed. It was positioned on the septum in a good location. The lead was anchored to the pectoral muscle with 0 silk sutures over a plastic collar.
At this point, I moved to the other side of the existing system. After infiltration with lidocaine, an incision was made at the upper margin of the existing pocket. The pocket was opened and the device and leads were freed of adhesions. I utilized a blunt tunneling tool and started tunneling across from the left to the right side. I went slightly lower and came back up to avoid the patient's ribs and reduce the discomfort or bulging of the lead. The patient is very thin. I was able to get into an area with some subcutaneous tissue. Utilizing blunt dissection, the tunneling tool was advanced as the tip was directed from the skin. We did so until a tunneling tool was across to the other side. I tied a wire to the tunneling tool and pulled it back. Through a wire, we inserted initially a 7-French, then a 10-French sheath to realize that the lead did not easily go through the sheath. I then upsized to a 12-French sheath, through which we were able to insert the lead from the right side and slide it through the sheath. I pulled the sheath out and the lead was pulled to the existing pocket on the left side. The old RV lead was disconnected and capped. The new lead was connected to the generator, which had 8 years of battery life left. The pocket was aggressively flushed with antibiotic solution and was closed with 2 layers of subcutaneous sutures and skin glue. We then flushed and closed the right-sided pocket.
PROCEDURE: Insertion of new right ventricular lead on the right side and tunneling across the chest to the existing pocket/device on the left side.
INDICATIONS: A ---female with a pacemaker in place for sinus bradycardia and paroxysmal AV block. Her device was initially implanted in 2014. She showed progressive increase in pacing threshold in the right ventricular lead over the past few months. We monitored carefully until it became clear that the lead will become dysfunctional. Her most recent pacing threshold was 4.25 volts at 1.5 milliseconds today. She comes in for insertion of a new lead.
The patient has end-stage renal disease and is on dialysis. She has a fistula on the left side. This is the same side where her original device is placed. I communicated with her surgeon who was concerned about inserting an additional lead in that area and requested that we go on the other side. For this reason, I plan to place the lead on the right side and tunnel it across the chest to the existing pocket/pacemaker.
PROCEDURE DESCRIPTION: The patient presented in the fasting state. Anesthesia was induced and maintained by anesthesiologist. The chest area was prepped and draped in the usual sterile fashion. An incision was made beneath the clavicle on the right side. Utilizing cautery, the incision was extended to the level of the pectoral fascia. Under fluoroscopy guidance, access into the right axillary vein was obtained and a 7-French sheath was inserted. The RV lead was inserted and actively fixed. It was positioned on the septum in a good location. The lead was anchored to the pectoral muscle with 0 silk sutures over a plastic collar.
At this point, I moved to the other side of the existing system. After infiltration with lidocaine, an incision was made at the upper margin of the existing pocket. The pocket was opened and the device and leads were freed of adhesions. I utilized a blunt tunneling tool and started tunneling across from the left to the right side. I went slightly lower and came back up to avoid the patient's ribs and reduce the discomfort or bulging of the lead. The patient is very thin. I was able to get into an area with some subcutaneous tissue. Utilizing blunt dissection, the tunneling tool was advanced as the tip was directed from the skin. We did so until a tunneling tool was across to the other side. I tied a wire to the tunneling tool and pulled it back. Through a wire, we inserted initially a 7-French, then a 10-French sheath to realize that the lead did not easily go through the sheath. I then upsized to a 12-French sheath, through which we were able to insert the lead from the right side and slide it through the sheath. I pulled the sheath out and the lead was pulled to the existing pocket on the left side. The old RV lead was disconnected and capped. The new lead was connected to the generator, which had 8 years of battery life left. The pocket was aggressively flushed with antibiotic solution and was closed with 2 layers of subcutaneous sutures and skin glue. We then flushed and closed the right-sided pocket.
twizzle
Guest
RV lead to existing device
Modifier 22 is not supported even though this is out of the ordinary with regards to the approach. If your provider had thoroughly documented that this was a particularly difficult procedure or if he said that the procedure took longer than usual and documented how much extra time over and above the usual time spent on placing a RV lead, then modifier 22 would be supported. Not the case here. You have to send records to the payer when modifier 22 is used on any procedure and the extra payment would be denied in this case due to lack of supporting documentation. All that would happen is a delay in payment which your provider would probably not appreciate.
Just because a procedure is slightly left field is not grounds for modifier 22. Use it wisely and sparingly.
33216 only.
Modifier 22 is not supported even though this is out of the ordinary with regards to the approach. If your provider had thoroughly documented that this was a particularly difficult procedure or if he said that the procedure took longer than usual and documented how much extra time over and above the usual time spent on placing a RV lead, then modifier 22 would be supported. Not the case here. You have to send records to the payer when modifier 22 is used on any procedure and the extra payment would be denied in this case due to lack of supporting documentation. All that would happen is a delay in payment which your provider would probably not appreciate.
Just because a procedure is slightly left field is not grounds for modifier 22. Use it wisely and sparingly.
33216 only.
