Wiki Help please...really not sure about the S&I if considered sep reportable or not

dkhclement

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Hello – Can I have someone look at this and see my thought process? I included as much info as possible to explain my code choices/reasoning.

37242 – embolization uterine artery (no fibroids)
36246-LT, 75736-59
36246-RT-59, 75736-59
76937

CPT codebook, page 461, if diagnostic angiography is necessary and performed at same session as interventional procedure, and meets above criteria mod 59 must be appended to the diagnostic radiological S&I codes to denote diagnostic work has been done following these guidelines.

Not sure if meets all criteria – no prior catheter-based angiographic study is available and a full diagnostic study is performed, and the decision to intervene is based on the diagnostic study…..was it based on the diagnostic study, not sure because pt had DUB and MD wanted to do this as bridge to menopause and pt was high risk for surgery. This is my main dilemma, seeing what's really reportable and what isn't. :confused::(

Procedure: Uterine Artery Embolization with Moderate Sedation

History: The patient is a 48 y.o. female with history of recurrent pulmonary embolism on lifelong anticoagulation with abnormal uterine bleeding. Prior endometrial biopsy had demonstrated no evidence for malignancy. Bleeding is refractory to contraceptives, D&C, endometial ablation and IUD. Patient is a high risk for surgery and is referred by OB-GYN for uterine artery embolization as bridge to menopause. Medical history includes hypertension, diabetes mellitus and blood transfusion. The patient does NOT have uterine fibroids.
Indication: N93.9 Abnormal uterine bleeding

Fluoroscopy time: 18.9 minutes

Sedation: Versed 1 mg and Fentanyl 50 micrograms were given intravenously. Continuous supervision and sedation medication administration began simultaneously at 08:34 and sedation end time was 10:01, for a total of 87 minutes of moderate sedation administered by an independent nurse trained in moderate sedation under my direct and continuous supervision.
Findings:
1. Dilated and tortuous right uterine artery embolized to 5-10 beat with 500-700 micron Embospheres. I77.1.
2. No evidence for dilated/tortuous left uterine artery. Embolization deferred.

Technique: The patient and site were identified. The prior studies and laboratory results were reviewed and the patient deemed acceptable for the procedure. The procedure, risks, alternatives and complications were discussed with the patient and informed consent was obtained in writing with witness and placed in the patient's chart. The patient agreed to proceed with the procedure. A preoperative timeout was performed.

The patient was placed in the supine position. The site was marked and the skin was prepped and draped in the usual sterile fashion. Local anesthesia was obtained with injection of 1% lidocaine solution.

Access into the right common femoral artery was obtained using ultrasound guidance and a micropuncture needle and 0.018 guidewire. An ultrasound image of the needle tip within the artery was permanently archived in PACS for future reference. (76937) A 5 French vascular introducer sheath was placed.

A 5 French Cobra (C2) glide catheter was inserted in combination with a 0.035 Glidewire and the catheter was advanced. The left internal iliac artery was selected and digital subtraction angiography was performed in multiple projections; however, the uterine artery could not be definitively visualized. (36246-LT, 75736-59 – see note above why I’m using -59) Given these findings, the decision was made to proceed with right uterine artery embolization.

The catheter was removed from the left sided circulation and the right internal iliac artery was selected using the Waltman's loop technique. Injection under fluoroscopy demonstrated the right uterine artery anatomy. (36246-RT-59, 75736-59) The right uterine artery was selected with a micorcatheter and wire. Digital subtraction angiography demonstrated the a dilated and tortuous right uterine artery. Embolization was performed from the mid right uterine artery until 5-10 beat stasis was achieved. Repeat contrast injection confirmed 5-10 beat stasis. Toradol 30 mg was administered intravenously. (37242)

Embolic material used:
1 vials 500-700 micron Embospheres

A 5 French flush catheter was then placed in the lower abdominal aorta. Digital subtraction angiography confirmed successful embolization of the right uterine artery; otherwise, there was no evidence for dilated/tortuous arteries supplying the uterus, particularly on the left.

Catheters and guidewires were removed and a sheath injection demonstrated the arterial puncture to be in the common femoral artery. A Mynx device was deployed to achieve hemostasis.

A sterile dressing was applied and the patient tolerated the procedure well. Patient left the angiography suite in unchanged condition.

The attending physician was present for the entire procedure. Images archived.

Impression: Uterine artery embolization, as described in detail above.

Plan: Continue anticoagulation. The patient will receive a patient controlled anesthesia pump (PCA) for pain control and be observed. Patient will be discharged with Percocet and NSAIDs for pain control at home and will not perform rigorous physical activity for one week. Patient will be contacted by Interventional Radiology by telephone to assess recovery and schedule clinic appointment. Follow up OB-GYN.
 
Last edited:
Hello – Can I have someone look at this and see my thought process? I included as much info as possible to explain my code choices/reasoning.

37242 – embolization uterine artery (no fibroids)
36246-LT, 75736-59
36246-RT-59, 75736-59
76937

CPT codebook, page 461, if diagnostic angiography is necessary and performed at same session as interventional procedure, and meets above criteria mod 59 must be appended to the diagnostic radiological S&I codes to denote diagnostic work has been done following these guidelines.

Not sure if meets all criteria – no prior catheter-based angiographic study is available and a full diagnostic study is performed, and the decision to intervene is based on the diagnostic study…..was it based on the diagnostic study, not sure because pt had DUB and MD wanted to do this as bridge to menopause and pt was high risk for surgery. This is my main dilemma, seeing what's really reportable and what isn't. :confused::(

Procedure: Uterine Artery Embolization with Moderate Sedation

History: The patient is a 48 y.o. female with history of recurrent pulmonary embolism on lifelong anticoagulation with abnormal uterine bleeding. Prior endometrial biopsy had demonstrated no evidence for malignancy. Bleeding is refractory to contraceptives, D&C, endometial ablation and IUD. Patient is a high risk for surgery and is referred by OB-GYN for uterine artery embolization as bridge to menopause. Medical history includes hypertension, diabetes mellitus and blood transfusion. The patient does NOT have uterine fibroids.
Indication: N93.9 Abnormal uterine bleeding

Fluoroscopy time: 18.9 minutes

Sedation: Versed 1 mg and Fentanyl 50 micrograms were given intravenously. Continuous supervision and sedation medication administration began simultaneously at 08:34 and sedation end time was 10:01, for a total of 87 minutes of moderate sedation administered by an independent nurse trained in moderate sedation under my direct and continuous supervision.
Findings:
1. Dilated and tortuous right uterine artery embolized to 5-10 beat with 500-700 micron Embospheres. I77.1.
2. No evidence for dilated/tortuous left uterine artery. Embolization deferred.

Technique: The patient and site were identified. The prior studies and laboratory results were reviewed and the patient deemed acceptable for the procedure. The procedure, risks, alternatives and complications were discussed with the patient and informed consent was obtained in writing with witness and placed in the patient's chart. The patient agreed to proceed with the procedure. A preoperative timeout was performed.

The patient was placed in the supine position. The site was marked and the skin was prepped and draped in the usual sterile fashion. Local anesthesia was obtained with injection of 1% lidocaine solution.

Access into the right common femoral artery was obtained using ultrasound guidance and a micropuncture needle and 0.018 guidewire. An ultrasound image of the needle tip within the artery was permanently archived in PACS for future reference. (76937) A 5 French vascular introducer sheath was placed.

A 5 French Cobra (C2) glide catheter was inserted in combination with a 0.035 Glidewire and the catheter was advanced. The left internal iliac artery was selected and digital subtraction angiography was performed in multiple projections; however, the uterine artery could not be definitively visualized. (36246-LT, 75736-59 – see note above why I’m using -59) Given these findings, the decision was made to proceed with right uterine artery embolization.

The catheter was removed from the left sided circulation and the right internal iliac artery was selected using the Waltman's loop technique. Injection under fluoroscopy demonstrated the right uterine artery anatomy. (36246-RT-59, 75736-59) The right uterine artery was selected with a micorcatheter and wire. Digital subtraction angiography demonstrated the a dilated and tortuous right uterine artery. Embolization was performed from the mid right uterine artery until 5-10 beat stasis was achieved. Repeat contrast injection confirmed 5-10 beat stasis. Toradol 30 mg was administered intravenously. (37242)

Embolic material used:
1 vials 500-700 micron Embospheres

A 5 French flush catheter was then placed in the lower abdominal aorta. Digital subtraction angiography confirmed successful embolization of the right uterine artery; otherwise, there was no evidence for dilated/tortuous arteries supplying the uterus, particularly on the left.

Catheters and guidewires were removed and a sheath injection demonstrated the arterial puncture to be in the common femoral artery. A Mynx device was deployed to achieve hemostasis.

A sterile dressing was applied and the patient tolerated the procedure well. Patient left the angiography suite in unchanged condition.

The attending physician was present for the entire procedure. Images archived.

Impression: Uterine artery embolization, as described in detail above.

Plan: Continue anticoagulation. The patient will receive a patient controlled anesthesia pump (PCA) for pain control and be observed. Patient will be discharged with Percocet and NSAIDs for pain control at home and will not perform rigorous physical activity for one week. Patient will be contacted by Interventional Radiology by telephone to assess recovery and schedule clinic appointment. Follow up OB-GYN.

I don't know if the patient was bleeding at the time of the procedure, but with the report saying abnormal uterine bleeding, I would code 37244 for the embolization. For your catheter selectivity, the uterine arteries are third order vessels, so you need 36247-50 ot -RT and -LT. Since there is no previous studies, and it's not a uterine fibroid study, you can bill for the selective pelvic arteriogram.
HTH,
Jim Pawloski, CIRCC
 
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