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Scenario Week of April 05, 2012:
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Operative Report

Preoperative Diagnoses:Second-degree atrioventricular block Bradycardia

Postoperative Diagnoses: Same

Procedure: Implant dual chamber pacemaker under fluoroscopic guidance

Device: Implanted Biotronik endocardial leads Atrial model #346369-45CM, serial number 28841897. Ventricular lead model #346366-53CM, serial number 28873738

Surgeon: Dr. Hartmann

Assistant: None

Anesthesia: Local MAC

Blood loss: Less than 20 ml

Complications: None

The patient is an 83-year-old female who presented to the hospital complaining of malaise and fatigue. Patient was found to be severely bradycardic secondary to a second degree AV block. She presents today for the procedure described above.

After informed consent, the patient was brought to the OR. 1% Xylocaine was applied to the left subclavicular fossa area in conjunction with local MAC. A 6-cm incision was then created via sharp dissection. Using blunt dissection, a pocket was created. Venous access was established under fluoroscopy to the apex of the right ventricle and on the right atrial appendage. After obtaining adequate pacing thresholds, the leads were each secured with 2-0 silk and then attached to a Biotronik dual chamber pacemaker. Set screws were firmly applied. The pulse generator was placed into the pocket and subcutaneous tissue was closed using interrupted 3-0 Vicryl, followed by 4-0 Monocryl, and then Dermabond. Sterile dressing was applied over the incision. Upon leaving the OR, the leads were confirmed to be in the proper position and the patient was hemodynamically stable. Sponge and needle counts were all correct. A chest x-ray was ordered and the patient was transferred back to the telemetry unit in stable condition.

Code this!


CPT Code
33208 Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular

ICD-9-CM Codes
426.13 Other second degree atrioventricular block
427.89 Other specified cardiac dysrhythmias, other

Under the main term “pacemaker” in the CPT index, subterm “insertion,” the coder is directed to code range 33206–33208. The three codes describe insertion of a new or replacement permanent pacemaker with code 33206 indicating atrial, 33207 indicating ventricular, and 33208 indicating both atrial and ventricular. The procedure above describes both the right ventricle and the right atrial appendage; therefore, 33208 would be the appropriate code.

In the alphabetic index of ICD-9-CM, under the main term “block” and the subterm “atrioventricular” are subterms that further identify second-degree block as Mobitz type I, classified to code 426.13, and Mobitz type II classified to code 426.12. Confirmation in the tabular listing reveals inclusion terms for code 426.13 Other second degree atrioventricular block, includes second degree heart block NOS, while code 426.12 specifically describes a Mobitz (type II) atrioventricular block. The documentation does not specify a particular name of the AV second degree block and without a physician query, the coder would assign 426.13 which includes a second degree AV block not otherwise specified.

The patient was also diagnosed with bradycardia. Under this main term in the ICD-9-CM alphabetic index, bradycardia is classified to code 427.89. Category 427.8 Other specified cardiac dysrhythmias, code 427.89 Other, is used to report this condition when no additional information is available to allow for greater coding specificity.

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