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Automatic Cardioverter Defibrillator implantation by keralaguest


									Automatic Cardioverter Defibrillator implantation - guideline
Coding Clinic, Third Quarter 1990 Page: 11 to 12

Implantation of Automatic Cardioverter Defibrillator

The implantable automatic cardioverter defibrillator is an electronic device designed to
detect and treat life-threatening tachyarrhythmias. The device consists of a pulse
generator and electrodes for sensing and defibrillating.

Implantation of the device system is indicated in patients who are at high risk for sudden
cardiac death due to ventricular tachyarrhythmias.

Patients at highest risk for sudden cardiac death syndrome include, but are not limited
to, those with:

   Congestive heart failure and/or depressed left ventricular function
   Previous myocardial infarction
   Significant ventricular ectopy
   Male gender

The automatic implantable cardioverter defibrillator devices are capable of giving several
successive shocks in an attempt to convert an arrhythmic episode. Battery depletion of
the device occurs after two to four years, during which time the device has the capacity
to deliver between 100--300 shocks. Monitoring time and number of shocks delivered
are interdependent influences on battery longevity.

A number of diagnostic tests are performed to evaluate a patient's need for the
automatic implantable cardioverter defibrillator device: Holter monitoring,
echocardiography, signal-averaged electrocardiograms, cardiac catheterization, and
cardiac electrophysiologic stimulation and recording studies (EP studies). EP studies
(37.26) procedurally resemble cardiac catheterization. However, several EP studies may
be performed during the course of patient evaluation, as well as after automatic
defibrillator implantation. Thus, EP studies and cardiac catheterization procedures are
frequently recorded as nonoperating room procedures performed at the time of
automatic cardioverter defibrillator implantation or replacement.

Implantation of the device system usually includes some form of thoracotomy (left
lateral, subcostal or subxyphoid) or median sternotomy approach with the lead system
placed intravascular and/or intrathoracic. Intrathoracic leads may be placed either intra-
or extra-pericardially. For example, the defibrillating leads may be placed on
both right and left ventricles and the rate sensing leads placed on the left ventricle. The
defibrillator pulse generator is placed in the left or right upper quadrant of the abdomen.

Total cardioverter defibrillator system implantation or replacement may be performed
either as a single procedure (37.94) during a given hospital admission, in association
with cardiac catheterization (37.21,37.22, or 37.23), and/or EP studies (37.26), or as a
two-stage procedure. When performed as a two-stage procedure, the lead system is
usually implanted (37.95) at the time of concommitant open-heart surgery, i.e., during
the initial surgery. On a subsequent day during the same admission, the pulse generator
is implanted (37.96).

For example:

Day 1 Coronary artery bypass (36.15) plus automatic defibrillator lead system implant
(37.95) plus EP studies (37.26)

Day 2 Implant cardioverter defibrillator generator (37.96)

Implantation of automatic defibrillator lead system only (37.95) or pulse generator only
(37.96) during a single hospital admission may occur on occasion. Total replacement of
the device system with leads (37.94) is also occasionally seen with or without EP studies
and/or cardiac catheterization.

When device battery depletion occurs the pulse generator portion of the system is
replaced (37.98), with or without replacement or revision of the lead(s). On occasion
lead(s) may be replaced (37.97). EP studies (37.26) could be performed before or after
the replacement procedure.

Repositioning of the lead(s) or pulse generator (37.99) or removal of cardioverter
defibrillator pulse generator (37.99) may be performed with or without cardiopulmonary
bypass (extracorporeal circulation) (39.61) and associated EP studies (37.26) and/or
cardiac catheterization (37.21, 37.22, 37.23)

Electrophysiologic Stimulation and Recording Studies

Electrophysiologic stimulation and recording studies, commonly referred to as EP
studies (EPS), are performed as part of the diagnosis and therapeutic management of
patients with ventricular tachycardia or ventricular fibrillation, both forms of cardiac
arrhythmia that carry a high risk of sudden death. The studies are also performed for
patients who have unexplained syncope and palpitation or supraventricular tachycardia.
After cardiac access is obtained either percutaneously or via cutdown, specialized
electrophysiologic catheter electrodes are inserted and guided into position under
fluoroscopy. Code 37.26, Cardiac electrophysiologic stimulation and recording studies, is
assigned for these studies.

EPS includes induction of arrhythmia, defibrillation threshold evaluation, testing
of sensing/pacing for arrhythmia termination, programming/reprogramming

For ICD-9-CM reporting, EPS evaluation is included in the cardioverter-defibrillator
implantation/replacement code 37.94.
EPS Study Upon Insertion of Defibrillator


The Central Office has received numerous requests regarding electrophysiologic studies
(EPS) that are performed during the implantation of an automatic
cardioverter/defibrillator (AICD). Code 37.94 includes implantation of defibrillator with
leads, formation of pocket, any transvenous leads, intraoperative procedures for
evaluation of lead signals, and obtaining defibrillator threshold measurements.
Therefore, based on the includes note at code 37.94, Implantation or replacement of
automatic cardioverter/defibrillator, total system [AICD], should a separate code be
assigned if an EPS study is done during the implantation of the AICD?


Cardiac electrophysiology (EP) studies performed during the implantation of a
total automatic cardioverter defibrillator (AICD) are included in code 37.94,
Implantation or replacement of automatic cardioverter/defibrillator, total system
[AICD]. The inclusion note "threshold measurements," mentioned at code 37.94,
refers to EP studies.

Therefore, if AICD testing were performed during the implantation of the AICD, do
not assign an additional code for EP studies. However, diagnostic EP studies
done prior to or following insertion of the AICD should be coded separately and
assigned to code 37.26. This information supersedes advice previously published
in Coding Clinic, First Quarter 1999, page 3.


Cardiac Resynchronization Therapy

Effective October 1, 2002, unique codes have been created to report cardiac
resynchronization therapy (also called biventricular pacing) procedures.

Cardiac resynchronization therapy (CRT) is similar to conventional pacemakers and
internal cardioverter-defibrillators (ICDs), but it differs in that it requires the implantation
of a special electrode within the coronary vein to attach the device to the exterior wall of
the left ventricle. CRT treats heart failure by providing strategic electrical stimulation to
the right atrium, right ventricle and left ventricle of the heart in order to re-coordinate
ventricular contractions and improve cardiac output. Please refer to Coding Clinic, Third
Quarter 2001, pages 3-5, for a more detailed description of CRT.

Cardiac resynchronization therapy defibrillators
Coding Clinic, Third Quarter 2001 Page: 4 to 5

Cardiac Resynchonization Therapy Defibrillators (CRT-Ds)
Note from 3M: As of October 1, 2002, codes 00.50 - 00.54 were created to report the
implantation of cardiac resynchronization therapy defibrillators and pacemakers. See
Coding Clinic, Fourth Quarter 2002 pgs 95-101.
 Cardiac Resynchronization Therapy Defibrillators (CRT-Ds) are designed to diagnose
and treat ventricular contractions and ventricular tachyarrhythmias in order to improve
cardiac performance and prevent sudden cardiac death.

 CRT-D requires the use of a cardiac resynchronization pulse generator with
defibrillation capabilities and three (3) leads [electrodes] in order to monitor and
provide electrical stimulation to the right atrium, right ventricle and left ventricle. Similar
to conventional automatic implantable cardioverter- defibrillator (AICD) procedures, the
defibrillation lead is positioned directly in the right ventricle and a pacing/sensing lead is
positioned directly in the right atrium. Unlike conventional AICD procedures, however,
CRT-D procedures require the implantation of a third lead within the coronary venous
system of the left ventricle in order to coordinate, or "synchronize" ventricular
contractions--and achieve cardiac resynchronization. The additional (third) lead is
inserted into the subclavian vein, cannulates the coronary sinus, and is transvenously
placed within the coronary veins attached to the exterior of the left ventricle.
Conventional pacemaker and ICD implants, on the other hand, require only two leads
(i.e., electrodes) that are inserted through larger, more accessible vessels and fed
directly into the right chambers of the heart.

 One approach for implanting the left ventricular (or coronary sinus) lead utilizes tools (or
devices) similar to those used for angioplasty. In this instance, a guide catheter is
inserted into the subclavian vein where it is then fed into the coronary sinus through the
ostium.* A guide wire is inserted through the guide catheter and into the coronary
sinus. The left ventricular lead is positioned over the (guide) wire and positioned in a
branch of the coronary veins. Finally, the guide wire is removed and replaced with a
finishing wire in order to stabilize the lead upon removal of the guide catheter (see figure

Although the implantation of the CRT-D requires the transvenous insertion of a lead
within the coronary venous system, along with two additional leads into the right atrium
and ventricle, the code assignment (37.94) does not differentiate between two or three
leads. This device should be coded in the same manner as an automatic implantable
cardioverter defibrillator (AICD) procedure.

 *In many cases, a left coronary angiogram (i.e., venogram) is required to illuminate and
diagnose the coronary venous system before inserting the left ventricle lead.

There are two types of cardiac resynchronization devices. One is a cardiac
resynchronization pacemaker, which is used to provide resynchronization therapy
to patients with ventricular dysfunction, who do not require an AICD (automatic

Implantation includes a (biventricular) pulse generator pacing device, pocket
formation, transvenous leads including placement of lead into left ventricular
coronary venous system and intraoperative procedures for evaluation of lead
A second device, cardiac resynchronization defibrillator, is similar to the
pacemaker but also includes an AICD (automatic cardioverter-defibrillator). The
AICD is used to deliver high-energy shocks to prevent and treat life threatening
ventricular tachyarrhythmias.

Both devices are inserted transvenously. Electrodes are placed directly within the
right atrium and right ventricle. A third electrode is inserted and placed within the
coronary vein, to facilitate its attachment to the external wall of the left ventricle.

REFERENCE: ICD-9-CM Maintenence Committee Minutes, 11/2001

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