Medical Coding Reimbursement

Medical Coding Reimbursement

Case 3

Procedure: Dual Chamber Implantable Cardioverter Defibrillator (ICD) Implantation

Pre-Procedure Diagnosis: Hypertrophic Cardiomyopathy, NSVT, SSS, Near Syncope

Procedure: The patient was brought to the Electrophysiology Lab in the
fasting state and continuous electrocardiographic monitoring was
instituted.

Anesthesia was performed by Dr Kiss and will be dictated separately by
him.

The left subclavicular fossa was prepped and draped in the usual sterile
fashion and 1% lidocaine was instilled for local anesthesia.  The incision
was made and the dissection was carried down to the level of the
pectoralis major fascia where a subcutaneous pocket was formed using blunt
dissection.  The axillary vein was entered with a Micropuncture thin
walled needle without difficulty at two separate locations, guided by
ultrasound, and guide wires were advanced into the central venous
circulation. Using the guide wires and two introducer sheaths, an ICD
electrode was advanced to the right ventricular septum, and a pacing
electrode was advanced to the right atrial appendage under fluoroscopic
guidance. Each electrode was anchored to the underlying pectoralis major
fascia with a single stitch of 2-0 non-absorbable suture.

These leads were attached to a dual chamber ICD which was placed in the
previously formed pocket with electrodes situated beneath it after the
pocket had been flushed with saline solution.

The ventricular electrode is a Medtronic Model # 6935M62 (Serial #
TDL515430V).  This is a bipolar, steroid-tipped, active fixation lead.
The R wave was 10 mV, the pacing impedance was 600 Ohms, and the
ventricular capture threshold was 0.75 V @ 0.5 ms.  The HVB impedance was
76.  There was no diaphragmatic pacing at 10 V. Medical Coding Reimbursement

The atrial electrode is a Medtronic Model # 5076 (Serial # PJN8450680).
This is a bipolar, steroid-tipped, active fixation lead.  The P wave was
1.3 mV, the pacing impedance was 650 Ohms, and the atrial capture
threshold was 1.3 V @ 0.5 ms.  There was no diaphragmatic pacing at 10 V.

The ICD pulse generator is a Medtronic Evera MRI DR.  Model # DDMB1D4,
Serial # PFZ622773S.  This device is placed in the subcutaneous location.

No defibrillation threshold testing was performed.

The wound was closed with a running stitch of 3-O absorbable suture and
the skin was closed with a running stitch of 4-O absorbable suture.
Topical skin adhesive was placed over the incision.

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The patient tolerated the procedure well.

Case 2

PROCEDURE: Right internal jugular vein tunneled hemodialysis catheter placement. PRE-PROCEDURE DIAGNOSIS: End-stage renal disease. Patient needs long term central venous access for hemodialysis. SEDATION: I was personally responsible for the administration of moderate sedation services during the procedure performed.  I confirm all of the requirements of moderate sedation were followed.  This included the use of an independent trained nurse who had no other duties during the procedure.  The drugs utilized were midazolam and fentanyl.  Continuous monitoring and face-to-face time began at 1707 hours and ended at 1747 hours.  Total minutes and further documentation can be found in the nursing/procedure log for this encounter date of service. Medical Coding Reimbursement TECHNIQUE: After application of 1% lidocaine for local anesthesia, the right internal jugular vein was accessed with a micropuncture system with real-time ultrasound visualization of vascular needle entry and permanent image recording. A guidewire was advanced under fluoroscopic guidance. A short incision was made in the infraclavicular region.  A subcutaneous tunnel was made to the venotomy site, through which the catheter was placed. The venotomy was dilated to accept the peel-away sheath, through which the leading end of the 14.5-French, 23 cm HemoStar dialysis catheter was advanced under fluoroscopic guidance.  Catheter tip positioned in the mid right atrium. The venotomy incision was closed with absorbable suture and skin adhesive, and the catheter was secured to the skin with suture. There was good flush and aspiration through both catheter lumens.  All lumens were flushed with heparin solution. Post-placement radiograph was obtained. A sterile dry dressing was placed over the catheter exit site. The procedure was well-tolerated without immediate complications. MEDICATIONS: Midazolam 0.5 mg IV Fentanyl 25 mcg IV Lidocaine 1% subcutaneous RADIATION DOSE: Air Kerma 12.7 mGy FLUOROSCOPIC TIME: 0.8 minutes. ESTIMATED BLOOD LOSS: None SPECIMENS OBTAINED: None. COMPLICATIONS: None. FINDINGS: 1. Ultrasound demonstrates a patent right internal jugular vein. 2. Post-placement radiograph shows an appropriately positioned tunneled catheter with the tip at the right atrium.

Impression: IMPRESSION: Successful placement of tunneled right internal jugular hemodialysis catheter (14.5-French, 23 cm HemoStar dialysis catheter). The catheter is ready for immediate use.

 

Case 1

PROCEDURES PERFORMED: Coronary Angiography

PROCEDURE:

Informed consent was obtained from the patient, and a time-out was
performed to verify the patient’s identification and planned procedure.
After the Allen’s test was used to confirm patency of the ipsilateral
ulnar artery, the patient’s right radial artery site was prepped and
draped in sterile fashion, and anesthetized with 1% subcutaneous lidocaine
using a 25 gauge needle. The radial artery was then entered by
through-and-through puncture with a 22G angiocath needle. The needle was
then removed, followed by slow withdrawal of the angiocatheter until blood
return was seen, confirming intra-arterial position. A sheath kit wire
was then advanced, allowing for exchange of the angiocatheter for a 5-Fr
hydrophilic sheath. The sheath was then flushed with 2.5 mg of verapamil
diluted in blood, followed by 50 units/kg (up to maximum of 5000 units) of
heparin administered intravenously. A 180 cm Radial Glide Wire (1.5 mm J)
or Versicore wire was used for initial catheter advancement, and a 260 cm
0.035″ J-wire was used for subsequent catheter removal. Standard
angiography was performed using 5 Fr JR4 diagnostic catheters to engage
the left main (LM) and right coronary artery (RCA), respectively. Medical Coding Reimbursement

After the catheter was removed over the J-wire, the existing sheath was
withdrawn half-way out in preparation for removal. A VascBand was
positioned as appropriate, and 12 cc of air used to inflate the band
during simultaneous complete removal of the sheath. The amount of air was
then adjusted as need to ensure hemostasis while ideally allowing patency
of the radial artery as confirmed by pulse oximetry during transient
ipsilateral ulnar artery occlusion. No immediate complications. Estimate
blood loss: minimal. Specimens: none.

I reviewed the patient’s pre-sedation assessment and vital signs,
supervised and directed the moderate sedation with continuous face-to-face
attendance. My intra-service time was 38 min. Please see procedure log
or sedation record for more details.