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Question IR Cardio-Catherizations

allowry5

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Laotto, IN
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Can I please get help on the following. I have no idea all the codes I am suppose to have. I have came up with 37242 and 10030. Then with the caths 36245, 36246, 36247, and 36248 but how many of each? I am not understanding the branches and what should be coded and what would be included. Thanks for any help I can get.


EXAMINATION:
Procedure:
1. Abdominal aortogram via right common femoral artery catheterization.
2. Superior Mesenteric artery catheterization and angiogram (1st order branch).
3. Middle colic artery catheterization and angiogram (2nd order branch).
4. Left colic artery catheterization and angiogram (4th order branch).
5. Inferior mesenteric artery catheterization and angiogram (5th order branch, from SMA approach).
6. Inferior mesenteric artery coil embolization and postembolization angiogram.
7. Right iliac angiogram via injection of existing right iliac limb of aortobiiliac stent graft.
8. Right internal iliac artery catheterization and angiogram (1st order branch).
9. Right iliolumbar artery catheterization and angiogram (3rd order branch).
10. Right L4 lumbar artery catheterization and angiogram (5th order branch).
11. Endoleak sac catheterization and angiogram, coil embolization of endoleak sac, and post embolization angiogram (6th order branch).
12. Medial branch right iliolumbar artery catheterization and angiogram (4th order branch).
13. Median sacral artery catheterization and angiogram (5th order branch).
14. Left L5 lumbar artery catheterization and angiogram, coil embolization and post embolization angiogram (6 order branch).
15. Median sacral artery embolization and post embolization angiogram (5th order branch).
16. Right groin fluid collection (seroma) aspiration under ultrasound guidance.



Right groin fluid collection/seroma aspiration:
Given the recent seroma aspiration, scanning with ultrasound of the right groin was performed to determine if there was a recurrent seroma. Permanent images obtained and recorded demonstrate that there has been development of a recurrent right groin
seroma measuring 4.5 by 3.5 cm directly anterior to the right common femoral artery which prevented access. Therefore it was aspirated. Under real-time ultrasound guidance with ultrasound sterile probe cover a 4 French one-step multi sidehole catheter
was inserted from a right lateral approach. 40 cc of clear yellow fluid was obtained. Non purulent-appearing and patient afebrile and prior cultures were negative. This fluid was discarded. No significant residual fluid is present. The angiogram and
embolization was then performed.

Angiogram and embolization:
Using a 21-gauge micropuncture set, a retrograde right common femoral artery 5-French sheath was placed.
1. Abdominal aortogram via right common femoral artery catheterization. Marker catheter placed into the abdominal aorta at a level just above the renal arteries for aortogram.
2. Superior Mesenteric artery catheterization and angiogram (1st order branch). Performed with 5 French glide Cobra catheter.
3. Middle colic artery catheterization and angiogram (2nd order branch). Performed with 5 French glide Cobra catheter.
4. Left colic artery catheterization and angiogram (4th order branch). Performed with coaxial microcatheter through the Cobra catheter.
5. Inferior mesenteric artery catheterization and angiogram (5th order branch, from SMA approach). Performed with coaxial microcatheter through the Cobra catheter.
6. Inferior mesenteric artery coil embolization and postembolization angiogram. Although the IMA injection demonstrated no supply from the IMA to an endoleak, there are some small collateral branches off the IMA around the margin of the AAA sac and the
IMA origin was therefore embolized as prophylaxis to prevent recruitment in the future as a possible source for endoleak. The IMA measured approximately 1-2 mm. It was coil embolized with concerto 2 mm x 4 cm coils x3. Completion IMA angiogram
demonstrated complete stasis.
7. Right iliac angiogram via injection of existing right iliac limb of aortobiiliac stent graft. Five French glide Cobra catheter.
8. Right internal iliac artery catheterization and angiogram (1st order branch). Five French glide Cobra catheter. Due to tortuosity this was unstable. A 6.5 French torque able sheath had to be placed in the right internal iliac origin for stability.
Procedure was still difficult due to tortuosity.
9. Right iliolumbar artery catheterization and angiogram (3rd order branch). This was extremely difficult due to its origin off the proximal superior gluteal artery. With the sheath tip at the origin of the right superior gluteal artery and a 5 French
kumpe catheter remaining inside the sheath, a coaxial microcatheter was used to select the right iliolumbar artery for angiogram. A collateral perfuses the right L4 lumbar artery and endoleak. A medial branch also supplied the median sacral artery.
10. Right L4 lumbar artery catheterization and angiogram (5th order branch). Coaxial microcatheter used and advanced with difficulty the right iliolumbar artery, through a very tiny tortuous collateral and eventually access to the right L4 lumbar artery
was achieved and injection confirmed in endoleak from the right L4 lumbar artery.
11. Endoleak sac catheterization and angiogram, coil embolization of endoleak sac, and post embolization angiogram (6th order branch). Microcatheter advanced into the endoleak sac which is amorphous in shape measuring approximately 3 cm craniocaudad by
1.6 cm transverse. The endoleak sac was then embolized with the following target detachable coils: These were utilized as they are the most conformal coils and there was tenuous access through the tortuous origin of the right iliolumbar artery. 12 mm x
45 cm x 2, 10 mm x 40 cm, 14 mm by 50 cm, 10 mm x 40 cm, 8 mm x 30 cm x 2, 6 mm x 20 cm. Completion angiogram in the sac at this point demonstrated no significant flow in the sac other than minimal flow along the upper most portion which should
thrombose. At this point the intention was to then embolize the feeding right L4 lumbar artery which measured 4-5 mm however the next coil placed to do this was a 6 mm x 30 cm target coil which became lodged half way through the microcatheter and could
not be advanced out of the catheter. The catheter had been constantly flushed between each coil. Upon gently retracting the coil to remove it , it detached in the catheter. The coil could not be advanced with a coil pusher. It appeared stuck within
the microcatheter. It became evident that the entire catheter would have to be removed which was done. Due to long length of time in difficulty in initially advancing the catheter through the tiny iliolumbar collateral to the right L4 lumbar artery,
this was not pursued and re-attempted as it was felt that there was adequate coils within the endoleak sac itself.
12. Medial branch right iliolumbar artery catheterization and angiogram (4th order branch). Performed with new microcatheter as the CTA demonstrated that the median sacral artery possibly supplied a small portion of the endoleak and this branch
supplied the median sacral artery.
13. Median sacral artery catheterization and angiogram (5th order branch). Coaxial microcatheter. Injection in multiple views demonstrated no obvious actual supply to an endoleak however the median sacral artery branches into the right and left L5
lumbar arteries as on the CTA. As prophylaxis against future recruitment for an endoleak it was decided to embolize this region.
14. Left L5 lumbar artery catheterization and angiogram, coil embolization and post embolization angiogram (6 order branch). This was larger than the right L4 lumbar artery. Coaxial microcatheter utilized. This left L5 lumbar artery was embolized with
a target 4 mm x 8 cm coil, and 2 concerto 6 mm x 20 cm coils. The last coil extends from the proximal left L5 lumbar artery into the confluence of the left and right lumbar arteries and the distal tip of the median sacral artery.
15. Median sacral artery embolization and post embolization angiogram (5th order branch). This was then coil embolized with a target 5 mm x 15 cm coil and a concerto 6 mm x 20 cm coil. Completion angiogram.
16. Sheath removed. Hemostasis with manual compression.
 

Jim Pawloski

True Blue
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Location
Ann Arbor
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This is an interesting case. First, tell your doctor there is not such thing as a fourth of fifth order selective catheterization. This is how I would code this, however, I agree with your first two codes.
36247 for Lt Colic catheterization with 75726 for visceral angio.
36248 for middle colic artery with 75774 for imaging.
36247-rt,59 for catheterization of right L-4 from Iliolumbar artery with 75705-RT for imaging.
36248-rt,59 for catheterization of branch of right L-4 from Iliolumbar artery with 75774 for imaging.
36247-LT,59 for catheterization of Lt L-5 artery from Median Sacral artery with 75705-LT for imaging.

Thanks for the case,
Jim Pawloski, CIRCC, CPC-A
 
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