Date of Device Check
/
Month
/
Day
Year
Date
Patient Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
Patient Device History: Enrolled in Monitoring?
Yes
No
Baseline Rhythm
Underlying Rhythm
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Baseline Device Information
Device Information
Post Op
Follow up:
Device Company
ABT
BSC
BTK
MDT
Device Type
PPM
ICD
CRT
ILR
Model Number / Name
Serial Number
Implant Date
/
Month
/
Day
Year
Date
Battery Voltage / Longevity
Pacing Mode
Pacing Rate (LRL/URL)
Ap (%)
Vp (%)
ICD Charge Time
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Lead Information
Atrial Lead Information
P wave
mV
Atrial Fibrillation?
Yes
No
Atrial Impedance
A Threshold
in Volts
Pulse Width (ms)
RV Lead Information
RV R wave
RV Impedance
Shock Impedance
RV Threshold
Pulse Width
ms
LV Lead Information
LV R wave
LV Impedance
LV Threshold
LV Pulse Width
ms
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Arrhythmia Information
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Episodes / Therapy
Changes Made
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Arrhythmia Information
Any further information about arhythmias detected? If so, place information here.
SVT: Number
Number of beats
SVT Length
Time
SVT Atrial Rate
SVT V Rate
AT/AF: Number
Number of beats
AF Burden
Percentage
Afib Ventricular Rate
AFib Atrial Rate
VT/VF: Number
VT/VF Length
VT/VF Atrial Rate
ATP? If so, how many rounds?
Shock?
VT Monitor
VT Length
Time
V Rate During VT
A Rate (during VT)
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Billing
Interrogation
Please Select
93288 Pacemaker
93289 ICD
93291 ILR
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Programming
Please Select
Pacemaker
Defibrillator
ILR
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Programming
Please Select
93279 PPM Programming Single Lead
93280 PPM Programming Dual Lead
93281 PPM Programming Multiple Lead
93282 ICD Programming Single Lead
93283 ICD Programming Dual Lead
93284 ICD Programming Multiple Lead
93285 ILR Programming
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Date Completed
/
Month
/
Day
Year
Date
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