embolization and arteriograms help

LRKoschoreck

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I am really struggling with this case. Could someone please take a look and let me know what you think? I've put my codes in parentheses:

Under fluoroscopic guidance, the right common femoral artery was accessed with a micropuncture needle. Over a guide wire, the needle was exchanged for a 70cm 4-French Flexor sheath. A C2 catheter and sheath were then used to access the superior mesenteric artery and arteriogram was performed. (36245, 75726)

The C2 catheter and sheath were advanced into the common hepatic artery and arteriogram was performed. (75774)

Catheter and sheath combination was then advanced into the gastroduodenal artery and arteriogram was performed.
A 6-mm Amplatzer plug was successfully deployed in the gastroduodenal artery and successful embolization was achieved. (37204, 75894)

Contrast was injected through the proper hepatic artery for an arteriogram. (36248, 75774)

Attempts were made to access a right gastric artery arising from the proper hepatic artery with a Prowler 90 degrees microcatheter but were not successful.

C2 catheter was placed in the medial left hepatic artery and arteriogram was performed. MAA was injected separately via the right and the medial left left hepatic arteries. (36247, 75774)

Renegade Hi Flo microcatheter was used to select the gastrohepatic trunk and arteriogram was performed. (36246, 75726)
 
I am really struggling with this case. Could someone please take a look and let me know what you think? I've put my codes in parentheses:

Under fluoroscopic guidance, the right common femoral artery was accessed with a micropuncture needle. Over a guide wire, the needle was exchanged for a 70cm 4-French Flexor sheath. A C2 catheter and sheath were then used to access the superior mesenteric artery and arteriogram was performed. (36245, 75726)

The C2 catheter and sheath were advanced into the common hepatic artery and arteriogram was performed. (75774)

Catheter and sheath combination was then advanced into the gastroduodenal artery and arteriogram was performed.
A 6-mm Amplatzer plug was successfully deployed in the gastroduodenal artery and successful embolization was achieved. (37204, 75894)

Contrast was injected through the proper hepatic artery for an arteriogram. (36248, 75774)

Attempts were made to access a right gastric artery arising from the proper hepatic artery with a Prowler 90 degrees microcatheter but were not successful.

C2 catheter was placed in the medial left hepatic artery and arteriogram was performed. MAA was injected separately via the right and the medial left left hepatic arteries. (36247, 75774)

Renegade Hi Flo microcatheter was used to select the gastrohepatic trunk and arteriogram was performed. (36246, 75726)

Perhaps there is more to this report, but I do not see interpretation for the radiology (angiography) S&I. Also, Is there variant anatomy (ie replaced hepatic artery from SMA etc)? Based on normal anatomy my code scenario would be:
37204/75894
36247 (RT gastroduodenal artery, a branch of the celiac artery)
36245-59 (SMA, though I wonder if the doc meant Celiac artery)
36248 (x2) for RT/LT Hepatic Artery MMA injections.
I could not find (on any of my charts) the "Gastrohepatic trunk". If the doc meant the common hepatic artery, that is a pullback to a lesser artery and selection is already included.

HTH :)
 
Perhaps there is more to this report, but I do not see interpretation for the radiology (angiography) S&I. Also, Is there variant anatomy (ie replaced hepatic artery from SMA etc)? Based on normal anatomy my code scenario would be:
37204/75894
36247 (RT gastroduodenal artery, a branch of the celiac artery)
36245-59 (SMA, though I wonder if the doc meant Celiac artery)
36248 (x2) for RT/LT Hepatic Artery MMA injections.
I could not find (on any of my charts) the "Gastrohepatic trunk". If the doc meant the common hepatic artery, that is a pullback to a lesser artery and selection is already included.

HTH :)

I agree with Danny. probably need to go back to the doctor and confirm what vessels were selected and if there was any aberrant anatomy.
(and whether the angiograms were diagnostic or roadmapping)
 
Thanks for your help, Danny. Here is the full report with the S&I findings. It states a gastrohepatic trunk is present with a replaced lateral left hepatic artery. I did some research and found this diagram (#5) of a variation where the gastrohepatic trunk arises from the celiac artery, then splits to become the left gastric and the hepatic arteries. In that case, I guess it would be included as a lesser vessel as you said.


PROCEDURE:
Common hepatic artery arteriogram.
Gastroduodenal artery arteriogram.
Gastroduodenal artery embolization.
Proper hepatic arteriogram.
Medial Left hepatic artery arteriogram.
Superior mesenteric artery arteriogram.
Gastrohepatic trunk arteriogram.
MAA injection via right hepatic artery.
MAA injection via medial left hepatic artery.
Monitored I/V conscious sedation.

HISTORY:
Hepatic mass. Patient is being prepared for radioembolization with SIR spheres.

PROCEDURE IN DETAIL:
The risks, benefits, and alternatives of the procedure and associated intravenous sedation were discussed and informed consent was obtained. The patient was brought to the Interventional Suite where a verbal timeout was performed. The patient was prepped and draped in sterile fashion. Under carefully monitored conditions, the patient received physician directed moderate conscious IV sedation.
Under fluoroscopic guidance, the right common femoral artery was accessed with a micropuncture needle. Over a guide wire, the needle was exchanged for a 70cm 4-French Flexor sheath . A C2 catheter and sheath were then used to access the superior mesenteric artery and arteriogram was performed.
The C2 catheter and sheath were advanced into the common hepatic artery and arteriogram was performed.
Catheter and sheath combination was then advanced into the gastroduodenal artery and arteriogram was performed.
A 6-mm Amplatzer plug was successfully deployed in the gastroduodenal artery and successful embolization was achieved.
Contrast was injected through the proper hepatic artery for an arteriogram.
Attempts were made to access a right gastric artery arising from the proper hepatic artery with a Prowler 90 degrees microcatheter but were not successful.
C2 catheter was placed in the medial left hepatic artery and arteriogram was performed. MAA was injected separately via the right and the medial left left hepatic arteries.
Renegade Hi Flo microcatheter was used to select the gastrohepatic trunk and arteriogram was performed.
The catheters and sheath were removed. Starclose device was used for hemostasis. Patient tolerated the procedure well and there were no immediate complications.

FINDINGS:
The superior mesenteric arteriogram demonstrates classic anatomy. There is no tumor vascularity. No replaced hepatic arteries were present. The SMA branch vessels are patent.
The common hepatic arteriogram demonstrates classic hepatic arterial anatomy.
Gastroduodenal artery showed no evidence of neovascularity or supply to tumor. Successful embolization was achieved with 6 mm Amplatzer plug.
Proper hepatic artery showed a bifurcation into medial left and right hepatic arteries. A small right gastric artery arising from the proper hepatic artery was appreciated but could not be catheterized.
Neovascularity/tumor blush was appreciated supplied by the right hepatic artery in the right hepatic lobe.
The main portal vein and its branches were patent.
A gastrohepatic trunk is present with a replaced lateral left hepatic artery supplying segment 2 and 3.
MAA was injected via the right hepatic artery and the medial left hepatic artery.

IMPRESSION: Successful Hepatic Arterial Mapping.

PLAN: Patient will follow-up in 7 to 14 days for SIRT of the right hepatic lobe.


For the MAA injections, would the S&I be 75774 for each? I am new to IR and couldn't find guidance on how to code for them.

And just so I'm following, you can code the gastroduodenal selection in addition to the embolization and it isn't considered part of the procedure?

I really appreciate your help!
 
Thanks for your help, Danny. Here is the full report with the S&I findings. It states a gastrohepatic trunk is present with a replaced lateral left hepatic artery. I did some research and found this diagram (#5) of a variation where the gastrohepatic trunk arises from the celiac artery, then splits to become the left gastric and the hepatic arteries. In that case, I guess it would be included as a lesser vessel as you said.


PROCEDURE:
Common hepatic artery arteriogram.
Gastroduodenal artery arteriogram.
Gastroduodenal artery embolization.
Proper hepatic arteriogram.
Medial Left hepatic artery arteriogram.
Superior mesenteric artery arteriogram.
Gastrohepatic trunk arteriogram.
MAA injection via right hepatic artery.
MAA injection via medial left hepatic artery.
Monitored I/V conscious sedation.

HISTORY:
Hepatic mass. Patient is being prepared for radioembolization with SIR spheres.

PROCEDURE IN DETAIL:
The risks, benefits, and alternatives of the procedure and associated intravenous sedation were discussed and informed consent was obtained. The patient was brought to the Interventional Suite where a verbal timeout was performed. The patient was prepped and draped in sterile fashion. Under carefully monitored conditions, the patient received physician directed moderate conscious IV sedation.
Under fluoroscopic guidance, the right common femoral artery was accessed with a micropuncture needle. Over a guide wire, the needle was exchanged for a 70cm 4-French Flexor sheath . A C2 catheter and sheath were then used to access the superior mesenteric artery and arteriogram was performed.
The C2 catheter and sheath were advanced into the common hepatic artery and arteriogram was performed.
Catheter and sheath combination was then advanced into the gastroduodenal artery and arteriogram was performed.
A 6-mm Amplatzer plug was successfully deployed in the gastroduodenal artery and successful embolization was achieved.
Contrast was injected through the proper hepatic artery for an arteriogram.
Attempts were made to access a right gastric artery arising from the proper hepatic artery with a Prowler 90 degrees microcatheter but were not successful.
C2 catheter was placed in the medial left hepatic artery and arteriogram was performed. MAA was injected separately via the right and the medial left left hepatic arteries.
Renegade Hi Flo microcatheter was used to select the gastrohepatic trunk and arteriogram was performed.
The catheters and sheath were removed. Starclose device was used for hemostasis. Patient tolerated the procedure well and there were no immediate complications.

FINDINGS:
The superior mesenteric arteriogram demonstrates classic anatomy. There is no tumor vascularity. No replaced hepatic arteries were present. The SMA branch vessels are patent.
The common hepatic arteriogram demonstrates classic hepatic arterial anatomy.
Gastroduodenal artery showed no evidence of neovascularity or supply to tumor. Successful embolization was achieved with 6 mm Amplatzer plug.
Proper hepatic artery showed a bifurcation into medial left and right hepatic arteries. A small right gastric artery arising from the proper hepatic artery was appreciated but could not be catheterized.
Neovascularity/tumor blush was appreciated supplied by the right hepatic artery in the right hepatic lobe.
The main portal vein and its branches were patent.
A gastrohepatic trunk is present with a replaced lateral left hepatic artery supplying segment 2 and 3.
MAA was injected via the right hepatic artery and the medial left hepatic artery.

IMPRESSION: Successful Hepatic Arterial Mapping.

PLAN: Patient will follow-up in 7 to 14 days for SIRT of the right hepatic lobe.


For the MAA injections, would the S&I be 75774 for each? I am new to IR and couldn't find guidance on how to code for them.

And just so I'm following, you can code the gastroduodenal selection in addition to the embolization and it isn't considered part of the procedure?

I really appreciate your help!

OK here goes:
37204/75894/75898 for embolization, imaging and followup injection
36247/75726-26,59 (ultimate selection of GDA, and common hepatic angiography)
36245-59/75726-26,59 (selection and angiography of SMA)
36248 (x2)/75774-(26,59)(x2) (selection and angiographies of RT/LT hepatic arteies)

The gastrohepatic trunk is included in selection of other (higher order) arteries and should not be separately coded.

The MAA injections are usually performed for the subsequent Nuclear Medicine Study (sorry, I don't know the code off hand) which is separately reported.They do not warrant 75774 assignment.

And yes, the selection of the GDA is separate from the embolization of same.

The modifiers are highly dependent on the payor preference, and may be slightly different for your area.

HTH :)
 
OK here goes:
37204/75894/75898 for embolization, imaging and followup injection
36247/75726-26,59 (ultimate selection of GDA, and common hepatic angiography)
36245-59/75726-26,59 (selection and angiography of SMA)
36248 (x2)/75774-(26,59)(x2) (selection and angiographies of RT/LT hepatic arteies)

The gastrohepatic trunk is included in selection of other (higher order) arteries and should not be separately coded.

The MAA injections are usually performed for the subsequent Nuclear Medicine Study (sorry, I don't know the code off hand) which is separately reported.They do not warrant 75774 assignment.

And yes, the selection of the GDA is separate from the embolization of same.

The modifiers are highly dependent on the payor preference, and may be slightly different for your area.

HTH :)

I agree with the charges. I researched in the SIR coding manual, and they have listed in the Onocology section 77778 Interstitial radiation source application - complex. This is under the Yttrium -90 section. I am assuming that this is for the injection of the MAA. What do you think?
Thanks,
Jim Pawloski, R.T. (CV), CIRCC
 
I agree with the charges. I researched in the SIR coding manual, and they have listed in the Onocology section 77778 Interstitial radiation source application - complex. This is under the Yttrium -90 section. I am assuming that this is for the injection of the MAA. What do you think?
Thanks,
Jim Pawloski, R.T. (CV), CIRCC


I researched a few cases of mine. The injection of MAA (macroaggregated albumin) is part of a radiopharmaceutical localization of tumor distribution. The code range is 78800-78807, and is reported separate (from the angiography) by the Nuclear Medicine department. The Y90 application (Sirsphere) comes later, usually several days.

HTH :)
 
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