margaret fahy
Guru
Hi,
This is a venous organ blood sampling with several angiographies. Do we get just one billing of 36500/75893, or is there more billing to be gotten in this study? It is a right hepatic venous sampling. The angiograms seem to be for the end purpose of the venous organ sampling. Do we get to bill any of the angiographies?
All input would be most helpful.
Thanks.
CLINICAL HISTORY: 15-year-old male patient with history of
hyperinsulinemia. Here for selective arterial calcium stimulation
and hepatic venous sampling
PROCEDURE:
1. Ultrasound-guided access of right internal jugular vein.
2. Selective catheterization of right hepatic vein and venogram.
3. Ultrasound guided access of the right common femoral artery.
4. Selective catheterization of the celiac artery, then common
hepatic artery and then right hepatic artery and angiogram with
calcium stimulation and subsequent hepatic vein sampling.
5. Selective catheterization of the gastroduodenal artery artery
and angiogram with calcium stimulation and subsequent hepatic
vein sampling.
6. Selective catheterization of the superior pancreaticoduodenal
artery and angiogram with calcium stimulation and subsequent
hepatic venous sampling.
7. Selective catheterization of splenic artery and angiogram with
calcium stimulation in 3 sites (proximal, mid and distal splenic
artery) and subsequent hepatic venous sampling.
8. Selective catheterization of superior mesenteric artery and
angiogram with calcium stimulation and subsequent hepatic venous
sampling.
9. Hemostasis with manual compression.
PROCEDURE IN DETAILS:
The skin of the right neck was prepped and draped in sterile
fashion. Using US guidance a 21 gauge needle was inserted in the
right internal jugular vein. Once arterial blood return was
obtained a .018" Nitrex wire was placed into the vein and
advanced to the right atrium. The needle was removed and replaced
with a 4 French micropuncture sheath/dilator set. The wire was up
sized to a .035" Newton wire, and a 5 French vascular sheath was
placed into the vein. Selective catheterization of right hepatic
vein was performed utilizing 4 French KMP catheter and 0.035
Newton wire. Contrast was injected and venogram was obtained.
Venogram confirmed the catheter location in the right hepatic
vein. This also was proved with transabdominal ultrasound. The
catheter was exchanged into 5 French straight catheter which was
secured in the right hepatic vein throughout the procedure.
The skin of the right groin was prepped and draped in sterile
fashion. Using US guidance a 21 gauge needle was inserted in the
right common femoral artery. Once arterial blood return was
obtained a .018" Nitrex wire was placed into the artery and
advanced to the distal abdominal aorta. The needle was removed
and replaced with a 4 French micropuncture sheath/dilator set.
The wire was up sized to a .035" Newton wire, and a 5 French
vascular sheath was placed into the artery. Via the arterial
sheath a 5 French Rim was advanced into the proximal abdominal
aorta. Then selective catheterization of the celiac artery,
common hepatic artery and then right hepatic artery was
performed. The catheter was changed into 4 French JB one
catheter. Contrast was injected and angiogram was obtained.
Angiogram demonstrated celiac artery and its branches are
unremarkable. There is replaced left hepatic artery from
gastroduodenal artery. There was mild spasm in the right hepatic
artery secondary to catheterization. This was treated with
nitroglycerin 50 mcg. Then, selective arterial calcium
stimulation was performed and subsequent right hepatic venous
sampling was obtained as per protocol.
Then, selective catheterization of gastroduodenal artery was
performed. Contrast was injected and angiogram was obtained. This
confirmed the catheter tip in proper position. There was mild
spasm in the gastroduodenal artery. This was treated with
nitroglycerin 40 mcg. Then selective arterial calcium stimulation
was performed and subsequent right hepatic venous sampling was
obtained as per protocol.
Then, selective catheterization of the superior
pancreaticoduodenal artery was performed. Contrast was injected
and angiogram was obtained. This confirmed the catheter tip in
proper position. There was mild spasm and the pancreaticoduodenal
artery. This was treated with nitroglycerin 25 mcg. Then
selective arterial calcium stimulation was performed and
subsequent right hepatic venous sampling was obtained as per
protocol.
Then, selective catheterization of the splenic artery was
performed. Contrast was injected and angiogram was obtained. This
confirmed the catheter tip in proper position. Then selective
arterial calcium stimulation was performed and subsequent right
hepatic venous sampling was obtained as per protocol. This was
repeated in the proximal, middle and distal portions of the
splenic artery.
Then, selective catheterization of the superior mesenteric artery
was performed using 4 French Sos Omni catheter. Contrast was
injected and angiogram was obtained. This confirmed the catheter
tip in proper position. Then selective arterial calcium
stimulation was performed and subsequent right hepatic venous
sampling was obtained as per protocol.
The catheter and sheath in the femoral artery were then removed
and manual compression was applied until hemostasis was achieved
with manual compression. A sterile occlusive dressing was applied
at the site.
The catheter and sheath in the right jugular vein were then
removed and manual compression was applied until hemostasis was
achieved with manual compression. A sterile occlusive dressing
was applied at the site.
There were no complications and the patient left the IR Suite in
stable condition. Dr.was present for the entire
procedure.
FINDINGS:
CELIAC ARTERY: The celiac artery and its branches including
splenic, left gastric and common hepatic arteries are
unremarkable.
RIGHT HEPATIC ARTERY:
The course calibre and branching pattern of the right hepatic
artery is normal.
GASTRODUODENAL ARTERY:
There is a right gastric artery arising from the proximal
gastroduodenal artery. Normal pancreaticoduodenal arcade.
PANCREATICODUODENAL ARTERY:
The course and branching pattern of the pancreaticoduodenal
arteries are normal supplying the pancreatic head.
SPLENIC ARTERY:
The course calibre and branching pattern of the splenic artery is
normal. The pancreatic body and tail is supplied by pancreatic
branches off the splenic artery. There is a small gastric branch
off the proximal splenic artery.
SUPERIOR MESENTERIC ARTERY: The superior mesenteric artery
appears unremarkable. Selective calcium calcium stimulation with
subsequent right hepatic venous sampling was performed via the
origin of the superior mesenteric artery.
Selective arterial calcium stimulation with subsequent right
hepatic venous sampling was performed via the right hepatic
artery, gastroduodenal artery, pancreaticoduodenal artery, and
splenic artery in 3 sites (proximal mid and distal portions).
Permanent ultrasound and fluoroscopic images were obtained and
stored in the PACS system.
IMPRESSION
IMPRESSION
1.Selective arterial calcium stimulation with subsequent right
hepatic venous sampling was performed via the right hepatic
artery, gastroduodenal artery, pancreaticoduodenal artery,
splenic artery in 3 sites (proximal, mid and distal portions) and
origin of the superior mesenteric artery, as described above.
2. Selective angiography performed at each calcium injection of
the right hepatic artery, gastroduodenal artery,
pancreaticoduodenal artery, splenic artery in 3 sites (proximal,
mid and distal portions) and origin of the superior mesenteric
artery.
3. Left gastric branch noted off the proximal splenic artery in
addition to body and tail pancreatic branches.
4. Right gastric artery arising off the proximal gastroduodenal
artery.
This is a venous organ blood sampling with several angiographies. Do we get just one billing of 36500/75893, or is there more billing to be gotten in this study? It is a right hepatic venous sampling. The angiograms seem to be for the end purpose of the venous organ sampling. Do we get to bill any of the angiographies?
All input would be most helpful.
Thanks.
CLINICAL HISTORY: 15-year-old male patient with history of
hyperinsulinemia. Here for selective arterial calcium stimulation
and hepatic venous sampling
PROCEDURE:
1. Ultrasound-guided access of right internal jugular vein.
2. Selective catheterization of right hepatic vein and venogram.
3. Ultrasound guided access of the right common femoral artery.
4. Selective catheterization of the celiac artery, then common
hepatic artery and then right hepatic artery and angiogram with
calcium stimulation and subsequent hepatic vein sampling.
5. Selective catheterization of the gastroduodenal artery artery
and angiogram with calcium stimulation and subsequent hepatic
vein sampling.
6. Selective catheterization of the superior pancreaticoduodenal
artery and angiogram with calcium stimulation and subsequent
hepatic venous sampling.
7. Selective catheterization of splenic artery and angiogram with
calcium stimulation in 3 sites (proximal, mid and distal splenic
artery) and subsequent hepatic venous sampling.
8. Selective catheterization of superior mesenteric artery and
angiogram with calcium stimulation and subsequent hepatic venous
sampling.
9. Hemostasis with manual compression.
PROCEDURE IN DETAILS:
The skin of the right neck was prepped and draped in sterile
fashion. Using US guidance a 21 gauge needle was inserted in the
right internal jugular vein. Once arterial blood return was
obtained a .018" Nitrex wire was placed into the vein and
advanced to the right atrium. The needle was removed and replaced
with a 4 French micropuncture sheath/dilator set. The wire was up
sized to a .035" Newton wire, and a 5 French vascular sheath was
placed into the vein. Selective catheterization of right hepatic
vein was performed utilizing 4 French KMP catheter and 0.035
Newton wire. Contrast was injected and venogram was obtained.
Venogram confirmed the catheter location in the right hepatic
vein. This also was proved with transabdominal ultrasound. The
catheter was exchanged into 5 French straight catheter which was
secured in the right hepatic vein throughout the procedure.
The skin of the right groin was prepped and draped in sterile
fashion. Using US guidance a 21 gauge needle was inserted in the
right common femoral artery. Once arterial blood return was
obtained a .018" Nitrex wire was placed into the artery and
advanced to the distal abdominal aorta. The needle was removed
and replaced with a 4 French micropuncture sheath/dilator set.
The wire was up sized to a .035" Newton wire, and a 5 French
vascular sheath was placed into the artery. Via the arterial
sheath a 5 French Rim was advanced into the proximal abdominal
aorta. Then selective catheterization of the celiac artery,
common hepatic artery and then right hepatic artery was
performed. The catheter was changed into 4 French JB one
catheter. Contrast was injected and angiogram was obtained.
Angiogram demonstrated celiac artery and its branches are
unremarkable. There is replaced left hepatic artery from
gastroduodenal artery. There was mild spasm in the right hepatic
artery secondary to catheterization. This was treated with
nitroglycerin 50 mcg. Then, selective arterial calcium
stimulation was performed and subsequent right hepatic venous
sampling was obtained as per protocol.
Then, selective catheterization of gastroduodenal artery was
performed. Contrast was injected and angiogram was obtained. This
confirmed the catheter tip in proper position. There was mild
spasm in the gastroduodenal artery. This was treated with
nitroglycerin 40 mcg. Then selective arterial calcium stimulation
was performed and subsequent right hepatic venous sampling was
obtained as per protocol.
Then, selective catheterization of the superior
pancreaticoduodenal artery was performed. Contrast was injected
and angiogram was obtained. This confirmed the catheter tip in
proper position. There was mild spasm and the pancreaticoduodenal
artery. This was treated with nitroglycerin 25 mcg. Then
selective arterial calcium stimulation was performed and
subsequent right hepatic venous sampling was obtained as per
protocol.
Then, selective catheterization of the splenic artery was
performed. Contrast was injected and angiogram was obtained. This
confirmed the catheter tip in proper position. Then selective
arterial calcium stimulation was performed and subsequent right
hepatic venous sampling was obtained as per protocol. This was
repeated in the proximal, middle and distal portions of the
splenic artery.
Then, selective catheterization of the superior mesenteric artery
was performed using 4 French Sos Omni catheter. Contrast was
injected and angiogram was obtained. This confirmed the catheter
tip in proper position. Then selective arterial calcium
stimulation was performed and subsequent right hepatic venous
sampling was obtained as per protocol.
The catheter and sheath in the femoral artery were then removed
and manual compression was applied until hemostasis was achieved
with manual compression. A sterile occlusive dressing was applied
at the site.
The catheter and sheath in the right jugular vein were then
removed and manual compression was applied until hemostasis was
achieved with manual compression. A sterile occlusive dressing
was applied at the site.
There were no complications and the patient left the IR Suite in
stable condition. Dr.was present for the entire
procedure.
FINDINGS:
CELIAC ARTERY: The celiac artery and its branches including
splenic, left gastric and common hepatic arteries are
unremarkable.
RIGHT HEPATIC ARTERY:
The course calibre and branching pattern of the right hepatic
artery is normal.
GASTRODUODENAL ARTERY:
There is a right gastric artery arising from the proximal
gastroduodenal artery. Normal pancreaticoduodenal arcade.
PANCREATICODUODENAL ARTERY:
The course and branching pattern of the pancreaticoduodenal
arteries are normal supplying the pancreatic head.
SPLENIC ARTERY:
The course calibre and branching pattern of the splenic artery is
normal. The pancreatic body and tail is supplied by pancreatic
branches off the splenic artery. There is a small gastric branch
off the proximal splenic artery.
SUPERIOR MESENTERIC ARTERY: The superior mesenteric artery
appears unremarkable. Selective calcium calcium stimulation with
subsequent right hepatic venous sampling was performed via the
origin of the superior mesenteric artery.
Selective arterial calcium stimulation with subsequent right
hepatic venous sampling was performed via the right hepatic
artery, gastroduodenal artery, pancreaticoduodenal artery, and
splenic artery in 3 sites (proximal mid and distal portions).
Permanent ultrasound and fluoroscopic images were obtained and
stored in the PACS system.
IMPRESSION
IMPRESSION
1.Selective arterial calcium stimulation with subsequent right
hepatic venous sampling was performed via the right hepatic
artery, gastroduodenal artery, pancreaticoduodenal artery,
splenic artery in 3 sites (proximal, mid and distal portions) and
origin of the superior mesenteric artery, as described above.
2. Selective angiography performed at each calcium injection of
the right hepatic artery, gastroduodenal artery,
pancreaticoduodenal artery, splenic artery in 3 sites (proximal,
mid and distal portions) and origin of the superior mesenteric
artery.
3. Left gastric branch noted off the proximal splenic artery in
addition to body and tail pancreatic branches.
4. Right gastric artery arising off the proximal gastroduodenal
artery.
