diagnostics with embolizations

iamlou

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Hi,

I have an embolization case that seems to indicate that they did diagnostic workup before the decision to embolize. According to Dr. Z, "embolization codes (37241-37244) allow separate coding of catheter placements and associated diagnostic imaging." Since the report says that "transarterial embolization was elected" after all of the diagnostic imaging, wouldn't I code that imaging?

For the angiography leading up to the decision to embolize, I thought 36245-59 for catheter position in the iliac limb, and 75625 for aortography along with 75710-59 for the iliac imaging, and 75774x2 for imaging of the celiac and SMA.
Then for the embolization, I thought 37242 with 36245-59 for placement in the SMA, and 36246 for catheter placement in the middle colic artery.

I hope I'm close.

Thanks for any input and thoughts on this!

PROCEDURES PERFORMED:
Abdominal aortography, mesenteric angiography, transmesenteric arterial
abdominal aortic aneurysm Endosac embolization and proximal inferior
mesenteric artery embolization.
IMAGING MODALITY UTILIZED:
Color Doppler ultrasonography and fluoroscopy.
FLUOROSCOPY TIME: 46.9 minutes, 4933 mGy.
MODERATE SEDATION: Moderate sedation was utilized.
ANESTHESIA: Local.
ACCESS SITE:
Right common femoral artery retrograde.
CATHETER POSITION:
Proximal abdominal aorta, abdominal aortic aneurysm endograft iliac limb
(left), celiac artery, superior mesenteric artery, inferior mesenteric
artery (via SMA/IMA collateral), abdominal aortic aneurysm sac via
transarterial mesenteric approach.
CONTRAST UTILIZED: Omnipaque.
TECHNIQUE: The right common femoral artery was interrogated with color Doppler
ultrasonography. The right common femoral artery demonstrates normal color
Doppler waveform analysis, and appears patent. Under ultrasound guidance,
after achieving local anesthesia with 1 percent lidocaine, right common
femoral artery was accessed in retrograde fashion. Over a guidewire a 6
French sheath was inserted. Over the guidewire, through the sheath a 5
French pigtail catheter was placed in the proximal abdominal aorta. AP
abdominal aortography was performed. Catheter was exchanged over a
guidewire for a 5 French Reuter catheter which is positioned in the left
iliac limb. Selective injection was performed. Catheter was repositioned
in the celiac artery. Injection performed. Catheter was repositioned in
the SMA, injection performed. Correlation is made with CTA from ****.
There is a prominent meandering SMA to IMA collateral with the IMA filling
the aneurysm sac. This is the suspected source is a type II endoleak.
Transarterial embolization attempt was elected. Patient received a total
of 2000 units of heparin during the course of the procedure.
Subsequently, a coaxial 3 French Renegade (150 cm) microcatheter was
advanced into the proximal superior mesenteric artery. Using a series of
0.018 inch and 0.014 inch guidewires, negotiation into the middle colic
artery supplying the meandering artery was unsuccessful. As such, a 4
French C2 glide catheter was positioned into the proximal SMA. Through
this a 3 French Direxion Renegade STC (150 cm) straight microcatheter was
inserted. Through this a 0.018 inch double-angled glide wire GT was placed
into the acutely-angled origin of the middle colic artery. Over this the
microcatheter was advanced into the proximal middle colic artery.
Superselective injection performed. Intra-arterial nitroglycerin was
utilized throughout this phase of the procedure. The meandering artery
has a long serpiginous course.
Subsequently, over the 0.018 inch double-angled and curved Glidewire, as
well as a 0.014 inch Fathom guidewire, the catheter was carefully advanced
through the left upper quadrant, into the origin of the IMA. Injection was
performed. The catheter was further advanced into the endosac. Injections
were performed into the endosac. With the catheter in this position, three
0.018 inch detachable interlock coils were deployed (one-2 mm x 4 cm, two-3
mm x 6 cm). The catheter was carefully retracted across the endo-channel
to the origin of the IMA. At this level, an additional 3 mm x 6 cm
interlock coil was deployed. Completion injection demonstrates complete
occlusion of the IMA at the level of its origin, preservation of the
superior rectal, sigmoid branches as well as left colic branch. The
catheter was removed. With removal, additional intra-arterial
nitroglycerin was administered. Via the 4 French C2 glide catheter
positioned in the proximal and middle colic artery, completion injection
performed demonstrates preservation of SMA, middle colic and IMA arterial
circulation to the gut. Catheter removed. Sheath removed. Groin closed
using StarClose without incident. Sterile dressing applied.
FINDINGS:
Patent AneuRx aortic endograft. No type I, type III, type IV endoleak.
Patent celiac artery. Patent SMA. There is an SMA to IMA meandering
artery that retrograde fills the endosac, constituting a type II IMA
endoleak. As described in detail above, the endosac channel, and IMA
origin were embolized using transarterial approach via the SMA-IMA
meandering artery.
COMPLICATIONS: None.
IMPRESSION:
ABDOMINAL AORTOGRAPHY, MESENTERIC ANGIOGRAPHY DEMONSTRATES PATENT ANEURX
ENDOGRAFT DEVICE. NO TYPE I, TYPE III, TYPE IV ENDOLEAK. THE PROXIMAL
STENT RING OF THE ANEURX DEVICE IS CAUDALLY DISPLACED WITH RESPECT TO THE
ORIGIN OF THE RENAL ARTERIES. IT IS UNCERTAIN AS TO WHETHER THIS REFLECTS
MIGRATION OR INITIAL PLACEMENT. INITIAL PLACEMENT IMAGES ARE NOT AVAILABLE
TO DETERMINE ACCORDINGLY.
TYPE II IMA ENDOLEAK AS DESCRIBED IN DETAIL ABOVE, TREATED WITH
TRANSCATHETER ARTERIAL EMBOLIZATION VIA SMA/IMA COLLATERAL.
 

Jim Pawloski

True Blue
Messages
1,390
Location
Ann Arbor
Best answers
1
Hi,

I have an embolization case that seems to indicate that they did diagnostic workup before the decision to embolize. According to Dr. Z, "embolization codes (37241-37244) allow separate coding of catheter placements and associated diagnostic imaging." Since the report says that "transarterial embolization was elected" after all of the diagnostic imaging, wouldn't I code that imaging?

For the angiography leading up to the decision to embolize, I thought 36245-59 for catheter position in the iliac limb, and 75625 for aortography along with 75710-59 for the iliac imaging, and 75774x2 for imaging of the celiac and SMA.
Then for the embolization, I thought 37242 with 36245-59 for placement in the SMA, and 36246 for catheter placement in the middle colic artery.

I hope I'm close.

Thanks for any input and thoughts on this!

PROCEDURES PERFORMED:
Abdominal aortography, mesenteric angiography, transmesenteric arterial
abdominal aortic aneurysm Endosac embolization and proximal inferior
mesenteric artery embolization.
IMAGING MODALITY UTILIZED:
Color Doppler ultrasonography and fluoroscopy.
FLUOROSCOPY TIME: 46.9 minutes, 4933 mGy.
MODERATE SEDATION: Moderate sedation was utilized.
ANESTHESIA: Local.
ACCESS SITE:
Right common femoral artery retrograde.
CATHETER POSITION:
Proximal abdominal aorta, abdominal aortic aneurysm endograft iliac limb
(left), celiac artery, superior mesenteric artery, inferior mesenteric
artery (via SMA/IMA collateral), abdominal aortic aneurysm sac via
transarterial mesenteric approach.
CONTRAST UTILIZED: Omnipaque.
TECHNIQUE: The right common femoral artery was interrogated with color Doppler
ultrasonography. The right common femoral artery demonstrates normal color
Doppler waveform analysis, and appears patent. Under ultrasound guidance,
after achieving local anesthesia with 1 percent lidocaine, right common
femoral artery was accessed in retrograde fashion. Over a guidewire a 6
French sheath was inserted. Over the guidewire, through the sheath a 5
French pigtail catheter was placed in the proximal abdominal aorta. AP
abdominal aortography was performed. Catheter was exchanged over a
guidewire for a 5 French Reuter catheter which is positioned in the left
iliac limb. Selective injection was performed. Catheter was repositioned
in the celiac artery. Injection performed. Catheter was repositioned in
the SMA, injection performed. Correlation is made with CTA from ****.
There is a prominent meandering SMA to IMA collateral with the IMA filling
the aneurysm sac. This is the suspected source is a type II endoleak.
Transarterial embolization attempt was elected. Patient received a total
of 2000 units of heparin during the course of the procedure.
Subsequently, a coaxial 3 French Renegade (150 cm) microcatheter was
advanced into the proximal superior mesenteric artery. Using a series of
0.018 inch and 0.014 inch guidewires, negotiation into the middle colic
artery supplying the meandering artery was unsuccessful. As such, a 4
French C2 glide catheter was positioned into the proximal SMA. Through
this a 3 French Direxion Renegade STC (150 cm) straight microcatheter was
inserted. Through this a 0.018 inch double-angled glide wire GT was placed
into the acutely-angled origin of the middle colic artery. Over this the
microcatheter was advanced into the proximal middle colic artery.
Superselective injection performed. Intra-arterial nitroglycerin was
utilized throughout this phase of the procedure. The meandering artery
has a long serpiginous course.
Subsequently, over the 0.018 inch double-angled and curved Glidewire, as
well as a 0.014 inch Fathom guidewire, the catheter was carefully advanced
through the left upper quadrant, into the origin of the IMA. Injection was
performed. The catheter was further advanced into the endosac. Injections
were performed into the endosac. With the catheter in this position, three
0.018 inch detachable interlock coils were deployed (one-2 mm x 4 cm, two-3
mm x 6 cm). The catheter was carefully retracted across the endo-channel
to the origin of the IMA. At this level, an additional 3 mm x 6 cm
interlock coil was deployed. Completion injection demonstrates complete
occlusion of the IMA at the level of its origin, preservation of the
superior rectal, sigmoid branches as well as left colic branch. The
catheter was removed. With removal, additional intra-arterial
nitroglycerin was administered. Via the 4 French C2 glide catheter
positioned in the proximal and middle colic artery, completion injection
performed demonstrates preservation of SMA, middle colic and IMA arterial
circulation to the gut. Catheter removed. Sheath removed. Groin closed
using StarClose without incident. Sterile dressing applied.
FINDINGS:
Patent AneuRx aortic endograft. No type I, type III, type IV endoleak.
Patent celiac artery. Patent SMA. There is an SMA to IMA meandering
artery that retrograde fills the endosac, constituting a type II IMA
endoleak. As described in detail above, the endosac channel, and IMA
origin were embolized using transarterial approach via the SMA-IMA
meandering artery.
COMPLICATIONS: None.
IMPRESSION:
ABDOMINAL AORTOGRAPHY, MESENTERIC ANGIOGRAPHY DEMONSTRATES PATENT ANEURX
ENDOGRAFT DEVICE. NO TYPE I, TYPE III, TYPE IV ENDOLEAK. THE PROXIMAL
STENT RING OF THE ANEURX DEVICE IS CAUDALLY DISPLACED WITH RESPECT TO THE
ORIGIN OF THE RENAL ARTERIES. IT IS UNCERTAIN AS TO WHETHER THIS REFLECTS
MIGRATION OR INITIAL PLACEMENT. INITIAL PLACEMENT IMAGES ARE NOT AVAILABLE
TO DETERMINE ACCORDINGLY.
TYPE II IMA ENDOLEAK AS DESCRIBED IN DETAIL ABOVE, TREATED WITH
TRANSCATHETER ARTERIAL EMBOLIZATION VIA SMA/IMA COLLATERAL.

I would code 36247 for the IMA catheterization from the SMA, and 36245-XS for the celiac selective. Imaging would be 75726-59 for the celiac angio., and 75726-59 for the SMA injection. I would not bill for the iliac artery as there is no documentation of findings for the iliac artery. Abdominal Aorta is bundled in the visceral codes. 37242 would be correct for embolization.
HTH,
Jim Pawloski, CIRCC
 
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