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Hello all!
We attempted to bill 37204, 75894 along with 47505, 74305,47500,74320,47511,75982,47555,74363 but were questioned by our HIM coder.
Our tech is stating that there was a lot of blood and stated that a catheter leaves a bigger opening than a needle thus needing the gelfoam slurry. Can anyone give me an opinion?
Thanks so much!
Percutaneous transhepatic cholangiogram, percutaneous placement of internal/external biliary drainage catheter, biliary tract balloon dilatation, portal venous tract embolization, and cholangiogram on 11/22/13.
Clinical indication: Pancreatic cancer with extensive hepatic metastatic disease. Internal/external left-sided biliary drainage catheter previously placed. Right-sided percutaneous drain previously placed. Attempt to cross right-sided obstruction for internalization.
Informed consent was obtained. The patient was prepped and draped in the usual sterile fashion. Skin was anesthetized with 1% Xylocaine. The right-sided biliary drainage catheter was injected with contrast. Contrast flowed freely into right-sided portal vein branches. The bile ducts were not visualized. A 0.035 guidewire was advanced through the catheter and exchange was made for a Kumpe catheter. The catheter was slowly withdrawn as contrast was injected. Contrast flowed into the portal vein branches and then contrast was seen to enter a few right-sided intrahepatic bile ducts. Multiple attempts were made to advance a 0.018 guidewire into the biliary ductal system. These were unsuccessful. It was therefore elected to remove the Kumpe catheter and re-access the patient. The tract was embolized with a Gelfoam slurry as the Kumpe catheter was removed.
Under fluoroscopic guidance an AccuStick needle was placed into a right-sided intrahepatic bile duct. A percutaneous transhepatic cholangiogram was performed. The transhepatic cholangiogram shows severe narrowing of right-sided intrahepatic bile ducts. There is faint visualization of a long segment of severely narrowed more central right superior bile ducts. Multiple attempts were made to place a 0.018 guidewire in the biliary ductal system through this approach and these were unsuccessful. It was then elected to access a more peripheral right-sided duct. A more peripherally positioned right superior intrahepatic duct was then cannulated with a micropuncture needle. Contrast was injected confirming intraductal location. A 0.018 guidewire was then advanced through the ducts and across the obstruction into the duodenum. An AccuStick sheath was then placed into the common duct. A 0.035 Amplatz wire was then advanced into the duodenum. Over the Amplatz guidewire an attempt was made to advance an 8-French biliary drainage catheter across the obstruction. This was unsuccessful due to the tight narrowing. It was therefore elected to perform a balloon dilatation. The area of stricturing in the right hepatic duct and common duct was then balloon dilated with a 5-mm diameter x 4-cm-long PowerFlex balloon. Following balloon dilatation an 8-French external/internal biliary drainage catheter was placed with the distal pigtail in the duodenum and proximal sideports in the right hepatic ducts. A cholangiogram was then performed showing satisfactory position of the new external/internal biliary drainage catheter.
Result Impression
The initial cholangiogram showed the right-sided biliary drainage catheter was in a moderately large portal venous branch and was also in a bile duct. The biliary ductal system could not be accessed through this approach. Therefore it was elected to remove this biliary drainage catheter and embolized the tract with Gelfoam slurry.
Percutaneous transhepatic cholangiogram showing severe narrowing of central right-sided bile ducts.
A new right hepatic ductal PTHC was performed and a guidewire was advanced across the obstruction into the duodenum.
The 8-French biliary drainage catheter could not be advanced across the obstructed bile ducts. Therefore balloon dilatation of the bile ducts was performed.
Successful placement of 8-French external/internal biliary drainage catheter following performance of a new percutaneous access and balloon dilatation of the strictures.
We attempted to bill 37204, 75894 along with 47505, 74305,47500,74320,47511,75982,47555,74363 but were questioned by our HIM coder.
Our tech is stating that there was a lot of blood and stated that a catheter leaves a bigger opening than a needle thus needing the gelfoam slurry. Can anyone give me an opinion?
Thanks so much!
Percutaneous transhepatic cholangiogram, percutaneous placement of internal/external biliary drainage catheter, biliary tract balloon dilatation, portal venous tract embolization, and cholangiogram on 11/22/13.
Clinical indication: Pancreatic cancer with extensive hepatic metastatic disease. Internal/external left-sided biliary drainage catheter previously placed. Right-sided percutaneous drain previously placed. Attempt to cross right-sided obstruction for internalization.
Informed consent was obtained. The patient was prepped and draped in the usual sterile fashion. Skin was anesthetized with 1% Xylocaine. The right-sided biliary drainage catheter was injected with contrast. Contrast flowed freely into right-sided portal vein branches. The bile ducts were not visualized. A 0.035 guidewire was advanced through the catheter and exchange was made for a Kumpe catheter. The catheter was slowly withdrawn as contrast was injected. Contrast flowed into the portal vein branches and then contrast was seen to enter a few right-sided intrahepatic bile ducts. Multiple attempts were made to advance a 0.018 guidewire into the biliary ductal system. These were unsuccessful. It was therefore elected to remove the Kumpe catheter and re-access the patient. The tract was embolized with a Gelfoam slurry as the Kumpe catheter was removed.
Under fluoroscopic guidance an AccuStick needle was placed into a right-sided intrahepatic bile duct. A percutaneous transhepatic cholangiogram was performed. The transhepatic cholangiogram shows severe narrowing of right-sided intrahepatic bile ducts. There is faint visualization of a long segment of severely narrowed more central right superior bile ducts. Multiple attempts were made to place a 0.018 guidewire in the biliary ductal system through this approach and these were unsuccessful. It was then elected to access a more peripheral right-sided duct. A more peripherally positioned right superior intrahepatic duct was then cannulated with a micropuncture needle. Contrast was injected confirming intraductal location. A 0.018 guidewire was then advanced through the ducts and across the obstruction into the duodenum. An AccuStick sheath was then placed into the common duct. A 0.035 Amplatz wire was then advanced into the duodenum. Over the Amplatz guidewire an attempt was made to advance an 8-French biliary drainage catheter across the obstruction. This was unsuccessful due to the tight narrowing. It was therefore elected to perform a balloon dilatation. The area of stricturing in the right hepatic duct and common duct was then balloon dilated with a 5-mm diameter x 4-cm-long PowerFlex balloon. Following balloon dilatation an 8-French external/internal biliary drainage catheter was placed with the distal pigtail in the duodenum and proximal sideports in the right hepatic ducts. A cholangiogram was then performed showing satisfactory position of the new external/internal biliary drainage catheter.
Result Impression
The initial cholangiogram showed the right-sided biliary drainage catheter was in a moderately large portal venous branch and was also in a bile duct. The biliary ductal system could not be accessed through this approach. Therefore it was elected to remove this biliary drainage catheter and embolized the tract with Gelfoam slurry.
Percutaneous transhepatic cholangiogram showing severe narrowing of central right-sided bile ducts.
A new right hepatic ductal PTHC was performed and a guidewire was advanced across the obstruction into the duodenum.
The 8-French biliary drainage catheter could not be advanced across the obstructed bile ducts. Therefore balloon dilatation of the bile ducts was performed.
Successful placement of 8-French external/internal biliary drainage catheter following performance of a new percutaneous access and balloon dilatation of the strictures.