Question Embolization with selective catheterization...help please

uneeq3

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Hello, new to the forum. I would appreciate help coding this procedure. Thanks in advance.


Diagnostic Report - Radiology PROCEDURE SUMMARY:

Procedure performed:

1. Ultrasound-guided access of the right common femoral artery
2. Selective angiogram of celiac artery

3. Super-selective angiogram of right hepatic artery
4. Super-selective angiogram of right hepatic sub-segmental branch artery
5. Particle (embozene 250 um) embolization of right hepatic sub-segmental branch artery (supplying the right lobe superior exophytic tumor)

6. Super-selective angiogram of left hepatic artery
7. Super-selective angiogram of left hepatic sub-segmental branch artery (supplying the left lobe superior exophytic tumor)
8. Particle (embozene 500 um) embolization of left hepatic sub-segmental branch artery

9. Super-selective angiogram of left gastric artery
10. Super-selective angiogram of left gastric parasitized vessel
11. Particle (embozene 250 um) embolization of left gastric parasitized vessel (supplying the left lobe superior exophytic tumor)

12. Deployment of perclose closure device

Indication: Ruptured hepatic tumor, hemorrhagic shock
Pre-operative diagnosis: Hepatic tumor, suspected ruptured HCC, hemorrhagic shock, intraperitoneal hemorrhage
Post-operative diagnosis: Hepatic tumor, suspected ruptured HCC, hemorrhagic shock, intraperitoneal hemorrhage

Findings/Impression:
1. Limited right common femoral artery ultrasound demonstrates patency
2. Selective angiogram of celiac artery demonstrates
a) Numerous hepatic tumors with contrast blush
b) Pooling of contrast within both the right lobe superior exophytic tumor and left lobe superior exophytic tumor suspicious for slow contrast extravasation
c) Parasitized vessel from the left gastric artery supplying the left lobe superior exophytic lesion

3. Super-selective angiogram of the right hepatic artery demonstrates abnormal enlarged arteries supplying numerous tumors, including the target in question in the right liver dome
4. Super-selective angiogram of the right hepatic sub-segmental branch artery demonstrates target tumor to greater advantage
5. Successful particle embolization (embozene 250 um) of right hepatic sub-segmental branch artery (supplying the right lobe superior exophytic tumor)

6. Super-selective angiogram of the left hepatic artery demonstrates abnormal enlarged arteries supplying numerous tumors, including the target in question in the left superior
7. Super-selective angiogram of the left hepatic sub-segmental branch artery demonstrates target tumor to greater advantage
8. Successful particle embolization (embozene 500 um) of left hepatic sub-segmental branch artery (supplying the left lobe superior exophytic tumor)

9. Super-selective angiogram of left gastric artery demonstrates abnormal enlarged arteries supplying the left lobe superior exophytic tumor
10. Super-selective angiogram of the left gastric parasitized vessel demonstrates target tumor to greater advantage
11. Successful particle embolization (embozene 250 um) of left gastric parasitized vessel

12. Successful deployment of perclose closure device

Plan:
1. Right leg straight and supine for 6 hours post-procedure.

Anesthesia:
Moderate Sedation

Estimated blood loss: 10 ml

Complications: No immediate complications

PROCEDURE IN DETAIL:

Informed consent was obtained from the patient. The procedure was described in detail and all questions were answered. The benefits, possible outcomes and specific risks including, but not limited to, 1-3% risk of bleeding, infection, loss of life, non-target embolization, death and damage to adjacent structures were explained. The associated benefits and potential complications of conscious sedation were also explained and informed consent was obtained. Prior to procedure start, a time-out using two patient identifiers was performed with the attending interventional radiology physician, nurse and technologist present. Correct patient, procedure, site and side were confirmed.

The patient was placed on the fluoroscopy table in the supine position. The right groin was prepared and draped using all elements of maximal sterile barrier technique including full hand hygiene, skin preparation with 2% chlorhexidine wash for cutaneous antisepsis, sterile cap, sterile mask, sterile gown, sterile gloves and sterile full body drape as well as sterile gel and sterile ultrasound probe cover.

Conscious sedation was administered by a dedicated IR nurse under continuous monitoring by the IR team including attending physician. Conscious sedation start time was 09:25, end time was 11:55, for a total duration of 150 minutes. Midazolam and fentanyl were administered intravenously. Continuous vital sign, cardiac and respiratory monitoring was conducted throughout the entirety of the procedure. 10 ml of 1% lidocaine was administered subcutaneously for local anesthesia.

The right common femoral artery was evaluated under ultrasound and determined to be patent. Local anesthesia was then applied using 1% lidocaine. Real time ultrasound was used to visualize entry of the 21G micropuncture needle into the artery and a permanent ultrasound image was saved and stored. Using Seldinger technique, this was upsized to accommodate a 6F sheath.

No prior catheter-based angiographic study was available so an initial diagnostic study was performed and final treatment decisions based on the diagnostic study.

The celiac artery was selected using a 5F Sim1 catheter and angiogram was performed.

The right hepatic artery was selected using a Truselect and 0.016 Fathom wire and angiogram was performed.
The right hepatic branch artery was selected using a Truselect and 0.016 Fathom wire and angiogram was performed.
The right hepatic branch artery was embolized using 2150 um Embozene particles.

The left hepatic artery was selected using a Truselect and 0.016 Fathom wire and angiogram was performed.
The left hepatic branch artery was selected using a Truselect and 0.016 Fathom wire and angiogram was performed.
The left hepatic branch artery was embolized using 500 um Embozene particles.

The left gastric artery was selected using a Truselect and 0.016 Fathom wire and angiogram was performed.
The left gastric branch artery was selected using a Truselect and 0.016 Fathom wire and angiogram was performed.
The left gastric branch artery was embolized using 250 um Embozene particles.

The microcatheter was removed and final angiogram was performed through the Sim1 base catheter.

The sheath was removed and hemostasis was achieved with perclose closure device. A sterile dressing was applied. The patient tolerated the procedure well and was transferred from the IR department in stable condition.
 

Jim Pawloski

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Since your new, do you have any ideas of what you want to code? I'll give you a hint. You need three selective codes, one main imaging code, 3 additional codes, and one interventional code.
Good luck,
Jim Pawloski, CIRCC, R.T. (CV)
 

uneeq3

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Thank you, ok , I have 37243 for embolization, 75710 for initial angiogram extremity, 37246/75726 for left gastric, 37247/75774 initial beyond 3rd order left hepatic, and 37248/75774 additional beyond 3rd order for right hepatic.
 

such78

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37244 for control hemorrhage per clinical indication.
additional 75774 for celiac artery
76937 - ultrasound guidance for vascular access
 
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uneeq3

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Thank you. I recently received my COC certification and work in a hospital radiology department. I'm studying to learn more IR coding. I appreciate your time. :)
 

Jim Pawloski

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I have 36247 for the branch of the right hepatic, 36248 for the left hepatic branch, 36248 for the gastric branch, 75726 for the celiac artery, 75774 x 3 for the right hepatic, left gastric, and left hepatic. 76937 is for U/S vascular access, and 37244 is for embolization. I didn't code 75710 because the used a vascular closure device which bundles that sheath injection.
You did pretty well with this case.

Jim Pawloski, CIRCC
 

uneeq3

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Thank you. I know I have so much more to learn and I'm sure I'll have more questions/posts regarding IR procedures in the future. Again, I appreciate your time/help as well as others in the forum. Have a great day. :)

Lisa, COC
 
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