I could you some advice and recommendations for this procedure.
The physician states that he will require to bring patient back the following day for trans septal access to embolize the remainder of the bronchial artery from previous day. I will include the dictation below.
My question is can you bill for an additional bronchial artery embolization the next day? As you can only bill per surgical field. Additionally I am unware of any stand alone trans Septal access procedure code. Can anyone assist on how to charge for the trans septal approach. I am only aware of the trans septal add on code during cardiac ablation (93462) procedures. Should this then be coded with 93799? I would appreciate any assistance.
Day One:
A pulmonary artery type catheter was fluoroscopically monitored over a guidewire into the right main pulmonary artery. Pulmonary arteriogram was performed in multiple views with contrast injection at a rate of 20 cc/s for total of 40 cc. The pulmonary artery anatomy of the right lung is normal in appearance without thrombosis or vascular malformations appreciated
A needle and guidewire were then placed into the common femoral artery under ultrasound guidance and a 6 French sheath was again placed. A bronchial artery type catheter was then inflated over a guidewire into the right brachial artery trunk. Angiogram was performed which demonstrated a somewhat hyperplastic right brachial artery system with multiple abnormal venous connections in the peripheral right lung. These venous connections do coalescent although again the main venous complex or varix did not opacify. An abnormal venous connection was also identified from the superior right bronchial artery division to a right paraspinal vein in the neck
The superior division of the right bronchial artery was accessed with a microcatheter and particle embolization was performed utilizing 500-700 um particles
The remainder of the right brachial artery I believe needs embolization although question was raised as to whether paradoxical embolization could occur due to the size of the draining variceal vein. At this point I decided to stop the procedure and consult with the cardiac electrophysiology team to decide whether pulmonary vein venogram and balloon occlusion would be needed during the embolization
Day Two:
Transseptal access was performed under ICE imaging to allow for PV mapping to assess for the collateral return of the AVM's
Marked lipomatous hypertrophy of the septum was present but access was obtained with an 8.5 Fr Agilis sheath.
This procedure was performed in conjunction with the cardiology service. The cardiologist obtained access to the left atrium for pulmonary venogram.
As such the draining aberrant varicose pulmonary vein in the right chest could not be located. This could be either due to more complete thrombosis of the vein versus aorta battery connection to the main pulmonary veins through collateral vessels or due to ostial stenosis. At any rate it appears that the vessel would not need to be embolized or balloon occluded prior to the bronchial embolization.
The bilateral inguinal region had been prepped and draped. Maximum sterile barrier was used. 1% lidocaine was injected for local anesthesia. A access needle was inserted into the right common femoral artery and a guidewire was placed. A 6 French sheath was inserted. A Sarah catheter was inserted over a guidewire and fluoroscopically manipulated into the right bronchial artery trunk. Contrast injection demonstrated good positioning. A microcatheter was advanced into the midportion of the right bronchial artery and particle embolization was performed utilizing 500 to 700 um particles. Approximately 1 vial of particles was injected while slowly withdrawing the microcatheter back towards the bronchial artery trunk. Good stasis of blood flow within the right bronchial artery territory was achieved. The catheters were removed and hemostasis was obtained after applying manual pressure.
Successful particle embolization of the right bronchial artery under fluoroscopy. The draining aberrant varicose pulmonary vein could not be delineated from the left atrium.
My initial thoughts
Day one
Unilateral Pulmonary Angiogram with cath placement into right main pulmonary artery (75741 36014)
Bronchial Angiogram cath placement superior division of right bronchial artery (75726, 36217?)
Embolization of Bronchial Artery due to AVM (37242)
Day Two:
Pulmonary Vein Angiography/Transseptal/ICE (93799)
Cannot charge for embolization same surgical field as day one?
Thoughts?
The physician states that he will require to bring patient back the following day for trans septal access to embolize the remainder of the bronchial artery from previous day. I will include the dictation below.
My question is can you bill for an additional bronchial artery embolization the next day? As you can only bill per surgical field. Additionally I am unware of any stand alone trans Septal access procedure code. Can anyone assist on how to charge for the trans septal approach. I am only aware of the trans septal add on code during cardiac ablation (93462) procedures. Should this then be coded with 93799? I would appreciate any assistance.
Day One:
A pulmonary artery type catheter was fluoroscopically monitored over a guidewire into the right main pulmonary artery. Pulmonary arteriogram was performed in multiple views with contrast injection at a rate of 20 cc/s for total of 40 cc. The pulmonary artery anatomy of the right lung is normal in appearance without thrombosis or vascular malformations appreciated
A needle and guidewire were then placed into the common femoral artery under ultrasound guidance and a 6 French sheath was again placed. A bronchial artery type catheter was then inflated over a guidewire into the right brachial artery trunk. Angiogram was performed which demonstrated a somewhat hyperplastic right brachial artery system with multiple abnormal venous connections in the peripheral right lung. These venous connections do coalescent although again the main venous complex or varix did not opacify. An abnormal venous connection was also identified from the superior right bronchial artery division to a right paraspinal vein in the neck
The superior division of the right bronchial artery was accessed with a microcatheter and particle embolization was performed utilizing 500-700 um particles
The remainder of the right brachial artery I believe needs embolization although question was raised as to whether paradoxical embolization could occur due to the size of the draining variceal vein. At this point I decided to stop the procedure and consult with the cardiac electrophysiology team to decide whether pulmonary vein venogram and balloon occlusion would be needed during the embolization
Day Two:
Transseptal access was performed under ICE imaging to allow for PV mapping to assess for the collateral return of the AVM's
Marked lipomatous hypertrophy of the septum was present but access was obtained with an 8.5 Fr Agilis sheath.
This procedure was performed in conjunction with the cardiology service. The cardiologist obtained access to the left atrium for pulmonary venogram.
As such the draining aberrant varicose pulmonary vein in the right chest could not be located. This could be either due to more complete thrombosis of the vein versus aorta battery connection to the main pulmonary veins through collateral vessels or due to ostial stenosis. At any rate it appears that the vessel would not need to be embolized or balloon occluded prior to the bronchial embolization.
The bilateral inguinal region had been prepped and draped. Maximum sterile barrier was used. 1% lidocaine was injected for local anesthesia. A access needle was inserted into the right common femoral artery and a guidewire was placed. A 6 French sheath was inserted. A Sarah catheter was inserted over a guidewire and fluoroscopically manipulated into the right bronchial artery trunk. Contrast injection demonstrated good positioning. A microcatheter was advanced into the midportion of the right bronchial artery and particle embolization was performed utilizing 500 to 700 um particles. Approximately 1 vial of particles was injected while slowly withdrawing the microcatheter back towards the bronchial artery trunk. Good stasis of blood flow within the right bronchial artery territory was achieved. The catheters were removed and hemostasis was obtained after applying manual pressure.
Successful particle embolization of the right bronchial artery under fluoroscopy. The draining aberrant varicose pulmonary vein could not be delineated from the left atrium.
My initial thoughts
Day one
Unilateral Pulmonary Angiogram with cath placement into right main pulmonary artery (75741 36014)
Bronchial Angiogram cath placement superior division of right bronchial artery (75726, 36217?)
Embolization of Bronchial Artery due to AVM (37242)
Day Two:
Pulmonary Vein Angiography/Transseptal/ICE (93799)
Cannot charge for embolization same surgical field as day one?
Thoughts?
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