margaret fahy
Guru
When coding for the catheterizations only, prior to a procedure, does one code only the catheterization that was necessary to perform the procedure? How would you code this one? Recent CTA done which showed bleeding....or would you code the angiographies?
Narrative:
PROCEDURES:
DIAGNOSTIC ANGIOGRAM WITH EMBOLIZATION..............37244
PARACENTESIS WITH DRAIN PLACEMENT...............NOT ASKING ABOUT THE PARACENTESIS
HISTORY: 9-month-old male with biliary atresia status post
hepatoportoenterostomy on 09/30/2025 and status post coarctectomy
with aortic arch augmentation (homograft patch), division and
ligation of left subclavian artery, PDA ligation on 8/2025 and
found to have active bleeding from the spleen status post
paracentesis on 05/15/2026 and now in hemorrhagic shock requiring
massive transfusion protocol and on three vasopressors. Patient
is pending liver transplantation. Request is made for splenic
angiogram and possible paracentesis/drain placement given
possible abdominal compartment syndrome.
COMPARISON: CTA abdomen and pelvis on 05/15/2026
PROCEDURE I:
The skin of the right groin and abdomen was prepped and draped in
sterile sterile fashion. After local anesthesia using 0.2%
ropivacaine, a 21-gauge needle was inserted into the right common
femoral artery using ultrasound guidance. Once blood return was
obtained, a 0.018" Nitrex wire was placed in the artery and
advanced under fluoroscopic guidance to the aorta. The needle was
removed and a 4 French micropuncture sheath was placed over the
wire into the artery and utilized to exchange for a 0.035"
Glidewire. The side arm of the vascular sheath was connected to a
saline flush. Over the wire, a 4 French pigtail catheter was
advanced into the suprarenal abdominal aorta. Digital subtraction
aortogram was performed. The pigtail catheter was exchanged for a
4 French Sos catheter . Multiple attempts to select the celiac
artery were unsuccessful. The Sos catheter was exchanged for a 4
French Rim catheter and used to select the celiac artery. Digital
subtraction arteriography was performed. Using the Rim catheter
and Glidewire, the proximal splenic artery was selected. Digital
subtraction arteriography was performed which showed a bleed in
the lower pole of the spleen.
A 2.4 French Rebar microcatheter pre-loaded with a 0.016" Fathom
microwire were coaxially advanced through the Rim catheter and
used to select a lower pole splenic arterial branch arising just
proximal to the splenic hilum. Digital subtraction arteriography
was performed. Once the microcatheter was advanced to the distal
lower pole splenic arterial branch, embolization was performed
using a total of five pushable coils (three straight 1cm coils
and two tornado coils 3x2). Intermittent digital subtraction
arteriography was performed. Decrease in bleeding was noted.
Subsequently, the microcatheter was slightly retracted and a
small amount of 150 to 250 um PVA particles were used for
embolization. Postembolization digital subtraction arteriography
was performed which showed no residual arterial bleeding.
Decision was made to leave catheter in place while paracentesis
occurred in case the removal of fluid prompted splenic bleeding.
Contrast injection after decompression of abdomen showed no
recurrent arterial bleed. Decision was made to remove the
selective cathter. The 4 French vascular sheath was then sutured
in place and the sheath sidearm was connected to a continuos
infusion of KVO. Sterile dressing was applied to the right groin
to secure the indwelling vascular sheath.
The patient tolerated the procedure without difficult or signs of
immediate complication. were present for all procedures in its
entirety.The patient maintains intubated post procedure and was
transferred to the PICU.
FINDINGS:
Angiogram and Embolization: Abdominal aortogram demonstrated
small-caliber aorta with branching arterial vasculature due to
vasoconstriction due to combination of hypotension and
vasopressors. Celiac arteriogram demonstrated patency of the
common hepatic, left gastric, and splenic arteries, although
small in caliber. Splenic arteriogram demonstrated active
arterial bleeding arising from a lower pole splenic arterial
branch arising just proximal from the splenic hilum. Embolization
was performed using microcoils and 150-250 um PVA particles.
Postembolization splenic arteriogram demonstrated complete
resolution of active arterial bleeding and preservation of
enhancing splenic parenchyma involving the upper and mid poles.
The four French right common femoral artery vascular sheath
remained in placed and securely sutured and dressed in the event
of needing to perform a repeat secondary angiogram.
Paracentesis with Drain Placement: Ultrasound of all four
quadrants of the abdomen demonstrated large volume of complex,
heterogeneous ascites with blood products present. Placement of a
10.2 French multipurpose drainage catheter was placed in the
right upper quadrant the abdomen. A total of 600 mL of blood was
removed over the course of several hours. Postprocedure
ultrasound images demonstrated pigtail drainage catheter
appropriately positioned within the right upper quadrant of the
abdomen and decrease in complex, heterogeneous ascites.
Permanent ultrasound and fluoroscopic images were obtained and
stored in the PACS system.
Maggie213
Narrative:
PROCEDURES:
DIAGNOSTIC ANGIOGRAM WITH EMBOLIZATION..............37244
PARACENTESIS WITH DRAIN PLACEMENT...............NOT ASKING ABOUT THE PARACENTESIS
HISTORY: 9-month-old male with biliary atresia status post
hepatoportoenterostomy on 09/30/2025 and status post coarctectomy
with aortic arch augmentation (homograft patch), division and
ligation of left subclavian artery, PDA ligation on 8/2025 and
found to have active bleeding from the spleen status post
paracentesis on 05/15/2026 and now in hemorrhagic shock requiring
massive transfusion protocol and on three vasopressors. Patient
is pending liver transplantation. Request is made for splenic
angiogram and possible paracentesis/drain placement given
possible abdominal compartment syndrome.
COMPARISON: CTA abdomen and pelvis on 05/15/2026
PROCEDURE I:
The skin of the right groin and abdomen was prepped and draped in
sterile sterile fashion. After local anesthesia using 0.2%
ropivacaine, a 21-gauge needle was inserted into the right common
femoral artery using ultrasound guidance. Once blood return was
obtained, a 0.018" Nitrex wire was placed in the artery and
advanced under fluoroscopic guidance to the aorta. The needle was
removed and a 4 French micropuncture sheath was placed over the
wire into the artery and utilized to exchange for a 0.035"
Glidewire. The side arm of the vascular sheath was connected to a
saline flush. Over the wire, a 4 French pigtail catheter was
advanced into the suprarenal abdominal aorta. Digital subtraction
aortogram was performed. The pigtail catheter was exchanged for a
4 French Sos catheter . Multiple attempts to select the celiac
artery were unsuccessful. The Sos catheter was exchanged for a 4
French Rim catheter and used to select the celiac artery. Digital
subtraction arteriography was performed. Using the Rim catheter
and Glidewire, the proximal splenic artery was selected. Digital
subtraction arteriography was performed which showed a bleed in
the lower pole of the spleen.
A 2.4 French Rebar microcatheter pre-loaded with a 0.016" Fathom
microwire were coaxially advanced through the Rim catheter and
used to select a lower pole splenic arterial branch arising just
proximal to the splenic hilum. Digital subtraction arteriography
was performed. Once the microcatheter was advanced to the distal
lower pole splenic arterial branch, embolization was performed
using a total of five pushable coils (three straight 1cm coils
and two tornado coils 3x2). Intermittent digital subtraction
arteriography was performed. Decrease in bleeding was noted.
Subsequently, the microcatheter was slightly retracted and a
small amount of 150 to 250 um PVA particles were used for
embolization. Postembolization digital subtraction arteriography
was performed which showed no residual arterial bleeding.
Decision was made to leave catheter in place while paracentesis
occurred in case the removal of fluid prompted splenic bleeding.
Contrast injection after decompression of abdomen showed no
recurrent arterial bleed. Decision was made to remove the
selective cathter. The 4 French vascular sheath was then sutured
in place and the sheath sidearm was connected to a continuos
infusion of KVO. Sterile dressing was applied to the right groin
to secure the indwelling vascular sheath.
The patient tolerated the procedure without difficult or signs of
immediate complication. were present for all procedures in its
entirety.The patient maintains intubated post procedure and was
transferred to the PICU.
FINDINGS:
Angiogram and Embolization: Abdominal aortogram demonstrated
small-caliber aorta with branching arterial vasculature due to
vasoconstriction due to combination of hypotension and
vasopressors. Celiac arteriogram demonstrated patency of the
common hepatic, left gastric, and splenic arteries, although
small in caliber. Splenic arteriogram demonstrated active
arterial bleeding arising from a lower pole splenic arterial
branch arising just proximal from the splenic hilum. Embolization
was performed using microcoils and 150-250 um PVA particles.
Postembolization splenic arteriogram demonstrated complete
resolution of active arterial bleeding and preservation of
enhancing splenic parenchyma involving the upper and mid poles.
The four French right common femoral artery vascular sheath
remained in placed and securely sutured and dressed in the event
of needing to perform a repeat secondary angiogram.
Paracentesis with Drain Placement: Ultrasound of all four
quadrants of the abdomen demonstrated large volume of complex,
heterogeneous ascites with blood products present. Placement of a
10.2 French multipurpose drainage catheter was placed in the
right upper quadrant the abdomen. A total of 600 mL of blood was
removed over the course of several hours. Postprocedure
ultrasound images demonstrated pigtail drainage catheter
appropriately positioned within the right upper quadrant of the
abdomen and decrease in complex, heterogeneous ascites.
Permanent ultrasound and fluoroscopic images were obtained and
stored in the PACS system.
Maggie213