Removal/Placement of a Pacemaker

Hi. Patient had a loop recorder implanted in Dec 30, 2014. In July 2015 my doctor removed the loop recorder and inserted a Dual Chamber Pacemaker.. When we billed this we billed a 33284 for the removal of the loop recorder and a 33208 for the pacer insert. Medicare is denying stating Payment is included in allowance for other procedure. Was this billed correctly or should there be a modifier used? Please help !!! I have attached the notes:

Prior to the procedure, history and physical were performed, and informed
consent was obtained. She was held n.p.o. after midnight and given vancomycin 1 g, Versed 1 mg, and
Dilaudid 1 mg intravenously on call to the cath lab, where she was prepped and draped in the usual
fashion and the region beneath the left clavicle anesthetized with 2% lidocaine anesthesia. A
subclavian vein puncture was performed with a thin-walled 18-gauge needle after injection of
contrast in a left arm peripheral IV identifying the location of the subclavian vein. A short
stainless steel guidewire was inserted through the needle into the subclavian vein. The needle was
removed and the proximal portion of the guidewire clamped to a drape. An incision was made in line
with the insertion portion of the guidewire and parallel to the inferior border of the clavicle for
approximately 4 cm and extended in depth to the tissue overlying the pectoralis major muscle. A
subcutaneous pouch was dissected in the fascial plane above the pectoralis major muscle of
sufficient size to accommodate a pacemaker pulse generator and electrodes. Bleeding was controlled
with Bovie coagulation. A 10-1/2 French dilator and permanent pacemaker electrode insertion sheath
were advanced over the guidewire. The dilator was removed. The guidewire was left in place for
secondary access. A Guidant active fixation bipolar permanent pacemaker electrode, model 4136-53
cm, serial No. 29690232, was inserted through the sheath. The sheath was split and removed, leaving
the guidewire in place. The electrode was manipulated in an optimal pacing and sensing position in
the mid RV outflow tract interventricular septum with a formed stylus. Fifteen 360-degree clockwise
rotations were performed on the hub of the electrode with active fixation confirmed by visualization
of advancement of the screw tip and lack of displacement with gentle traction, then restoration of
optimal slack after removal of the stylet. The pacemaker analyzer documented a pacing threshold of
0.4 V at 0.5 milliseconds, impedance of 875 ohms, and R-wave sensing of 12.1 mV. A 2nd 10.5-French
dilator and permanent pacemaker electrode insertion sheath were advanced over the guidewire. The
dilator and guidewire were both removed and a Guidant active fixation permanent pacemaker electrode,
model 4469-45 cm, serial No. 588772 was advanced through the sheath. After a waiting time of 3
minutes, the electrode was manipulated into the region of the right atrial appendage with a J-formed
stylet provided by the manufacturer. Six 360-degree clockwise rotations were performed on the shaft
of the electrode with active fixation confirmed by lack of displacement with removal of the stylet.
A pacing threshold of 0.4 V at 0.5 milliseconds, impedance of 527 ohms and P-wave sensing of 2.6 mV
was recorded. A 2-0 silk suture was placed around the insertion point of the electrodes at the base
of the pouch to prevent back-bleeding. A second 2-0 silk suture was placed in the pectoralis major
muscle, tied tightly around the insulating cuffs on the shafts of the electrode provided for
anchoring purposes. The pouch was irrigated with an antibiotic solution of bacitracin and
polymyxin, and the electrodes were connected to a Boston Scientific DDDR permanent pacemaker pulse
generator, model K063, serial No. 143819. The pouch was irrigated with antibiotic solution of
bacitracin and polymyxin. The operator's gloves were changed per protocol. The generator and
electrodes were positioned in the pouch, the subcutaneous tissue closed with running 3-0 Vicryl, and
the skin was closed with skin clips. After completion of the pacemaker implantation, fluoroscopy
showed no pneumothorax and unchanged position of the electrodes. The skin overlying the previously-
implanted loop recorder in the 3rd intercostal space, midclavicular line, was anesthetized with 2%
lidocaine anesthesia. An incision was made in line with the implant incision and the loop recorder
was explanted. The pouch was irrigated with an antibiotic solution of bacitracin and polymyxin.
The operator's gloves were changed per protocol. The subcutaneous tissue was closed with running 3-
0 Vicryl. The skin was closed with skin clips. The patient tolerated the procedure well. There
were no complications. She was returned to her room in good condition.

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