EricRmi
Contributor
Good Day!
The purpose of this post is for the readers to help me point out my mistakes or missed items that could be coded and billed.
It's my first time coding a surgery procedure.
It is a Uterine Fibroid Embolization procedure.
I've read the guidelines but I just want to make sure that I captured everything correctly.
Here are the codes: (please correct me or add any codes I missed)
ICD-10-CM code = D25.9 Leiomyoma of uterus, unspecified
CPT codes = 37243,
additional cpt codes = 36247-50-59 (for common iliac artery bilateral), 36248-50-59 (for internal iliac bilateral and uterine artery bilateral)
=======================================
PREOPERATIVE DIAGNOSIS
Symptomatic leiomyomata uterus.
POSTOPERATIVE DIAGNOSIS
Symptomatic leiomyomata uterus, improved.
PROCEDURE
1. Pelvic arteriography pre-embolization.
2. Bilateral common iliac arteriography.
3. Bilateral internal iliac arteriography.
4. Bilateral uterine artery arteriography.
8. Abdominal arteriography,left ovarian artery embolization
9. Placement of arteriotomy closure device.
ANESTHESIA
Local by surgeon.
Conscious sedation by ______ _____ (CRNA).
INDICATIONS
Patient with symptomatic leiomyomata uncontrolled by outpatient management. Alternatives discussed with patient prior to procedure include surgery (hysterectomy, myomectomy), medical management, and expectant care. Benefits of uterine artery embolization discussed prior to surgery. Risks discussed including, but not limited to, premature menopause, infection, prolapse of myomata, non target embolization, failure. Patient verbalizes understanding and acceptance of benefits, risks, and alternatives to uterine artery embolization. Wishes to proceed with embolization. Laboratory values including coagulation studies, creatinine, and complete blood count were all reviewed prior to the start of the procedure, and found to be acceptable to proceed.
DESCRIPTION OF PROCEDURE
The patient was prepped and draped and placed in the dorsal position. Patient was given intravenous antibiotics for prophylaxis. Local anesthetic was applied over the left common femoral artery and a 21-gauge micropuncture needle was used to enter the left common femoral artery. The artery was dilated and eventually a 0.035-inch wire was advanced into the aorta. Over this, a 6-French introducing sleeve was inserted. The sleeve was continuously irrigated with Ringer lactate and 10 units of heparin run at a rate to keep open. Through the introducing sleeve an Omni Flush 5-French injection catheter was advanced into the abdominal aorta caudad to the aortic bifurcation.
Prior to embolization, patient was given the following intravenous medications 125 mg of Solu-Medrol, 1000 mg of Tylenol, 2 grams of Ancef.
A power injector was then used to obtain a pelvic angiogram using 10 cc of contrast material per second for 2 seconds for a total of 20 cc of contrast. A good image was taken confirming extremely vascular uterus myoma. There were no gross anatomic abnormalities.
With the Benson wire advancing, the Omni Flush catheter was then pulled down into the left common iliac artery, and a left common iliac arteriogram demonstrated the bifurcation of this artery. Under fluoroscopic vision the Omni Flush catheter and the glidewire were pulled down into the left internal iliac artery. The Omni Flush catheter was then exchanged for the 5-French Hunter 2 catheter. Using road mapping and glidewire, the Hunter 2 catheter was then advanced to the horizontal portion of the left uterine artery.
The orifice of the uterine artery on the left side was identified; however, the flow had been stopped by a previous embolization and no embolization was done.
The Hunter 2 catheter was then advanced over the Benson glidewire to the aortic arch. Under fluoroscopic vision the Terumo Glidewire was introduced into the right common iliac artery. Using road mapping techniques the angled glidewire was introduced into the internal right iliac artery and the catheter advanced.
The orifice of the right uterine artery was identified, again, it had been successfully embolized in a prior procedure. No embolization was necessary.
The tip of the catheter was then further withdrawn into the common iliac artery on the patient's right side where an arteriogram demonstrated clear flow to the external femoral artery and stasis within the uterine artery and no non-target embolization.
The catheter was then exchanged for an Omni Flush 5-French catheter which was inserted into the aorta. The pelvis was imaged again with a power injector using the same injection frequency of 10 cc of contrast per second for 2 seconds for a total of 20 cc of contrast. Angiography of the pelvis revealed stasis within the pelvic vessels and good flow within the other pelvic structures.
The Omni Flush catheter was then advanced to the level of the renal arteries. The image intensifier was placed at the pelvic rim and with power injection using 20 cc of contrast per second for 1.5 seconds for a total of 30 cc of contrast, search for an ovarian artery blood supply was done. The left ovarian artery arising approximately 3 cm distal to the renal arteries was identified and noted to be supplying the uterus. It was cannulated with an SMS-1 catheter and through that a microcatheter(Progreat) was advanced. Prior to embolization of the artery, the patient was given a 20 mg transarterial injection of Toradol. Embolization was performed with two vials of 200-500 micron PVA particles(Merit). Following embolization, the patient was given 5 cc of 1% buffered lidocaine for pain relief.
Also noted was a right ovarian artery. The patient's had been exposed to radiation for a considerable period and will be offered a second procedure to embolize the right ovarian artery in the future if needed.
A contrast injection was performed through the introducing sheath to verify the appropriate location for deployment of an arteriotomy closure device. An Angio-Seal arteriotomy closure device was then applied over the .035-inch glidewire and deployed successfully into the arteriotomy site. No bleeding and no hematomata were seen at the end of the application. Urine was clear, feet were warm, dorsalis pedis pulses were strong bilaterally. Pulse oximeter on the first right metatarsal read 100% oxygen saturation on room air. The patient left the procedure room in stable condition.
TOTAL FLUOROSCOPY TIME
16 minutes 20 seconds
TOTAL CONTRAST USED
160 cc of Visipaque
The purpose of this post is for the readers to help me point out my mistakes or missed items that could be coded and billed.
It's my first time coding a surgery procedure.
It is a Uterine Fibroid Embolization procedure.
I've read the guidelines but I just want to make sure that I captured everything correctly.
Here are the codes: (please correct me or add any codes I missed)
ICD-10-CM code = D25.9 Leiomyoma of uterus, unspecified
CPT codes = 37243,
additional cpt codes = 36247-50-59 (for common iliac artery bilateral), 36248-50-59 (for internal iliac bilateral and uterine artery bilateral)
=======================================
PREOPERATIVE DIAGNOSIS
Symptomatic leiomyomata uterus.
POSTOPERATIVE DIAGNOSIS
Symptomatic leiomyomata uterus, improved.
PROCEDURE
1. Pelvic arteriography pre-embolization.
2. Bilateral common iliac arteriography.
3. Bilateral internal iliac arteriography.
4. Bilateral uterine artery arteriography.
8. Abdominal arteriography,left ovarian artery embolization
9. Placement of arteriotomy closure device.
ANESTHESIA
Local by surgeon.
Conscious sedation by ______ _____ (CRNA).
INDICATIONS
Patient with symptomatic leiomyomata uncontrolled by outpatient management. Alternatives discussed with patient prior to procedure include surgery (hysterectomy, myomectomy), medical management, and expectant care. Benefits of uterine artery embolization discussed prior to surgery. Risks discussed including, but not limited to, premature menopause, infection, prolapse of myomata, non target embolization, failure. Patient verbalizes understanding and acceptance of benefits, risks, and alternatives to uterine artery embolization. Wishes to proceed with embolization. Laboratory values including coagulation studies, creatinine, and complete blood count were all reviewed prior to the start of the procedure, and found to be acceptable to proceed.
DESCRIPTION OF PROCEDURE
The patient was prepped and draped and placed in the dorsal position. Patient was given intravenous antibiotics for prophylaxis. Local anesthetic was applied over the left common femoral artery and a 21-gauge micropuncture needle was used to enter the left common femoral artery. The artery was dilated and eventually a 0.035-inch wire was advanced into the aorta. Over this, a 6-French introducing sleeve was inserted. The sleeve was continuously irrigated with Ringer lactate and 10 units of heparin run at a rate to keep open. Through the introducing sleeve an Omni Flush 5-French injection catheter was advanced into the abdominal aorta caudad to the aortic bifurcation.
Prior to embolization, patient was given the following intravenous medications 125 mg of Solu-Medrol, 1000 mg of Tylenol, 2 grams of Ancef.
A power injector was then used to obtain a pelvic angiogram using 10 cc of contrast material per second for 2 seconds for a total of 20 cc of contrast. A good image was taken confirming extremely vascular uterus myoma. There were no gross anatomic abnormalities.
With the Benson wire advancing, the Omni Flush catheter was then pulled down into the left common iliac artery, and a left common iliac arteriogram demonstrated the bifurcation of this artery. Under fluoroscopic vision the Omni Flush catheter and the glidewire were pulled down into the left internal iliac artery. The Omni Flush catheter was then exchanged for the 5-French Hunter 2 catheter. Using road mapping and glidewire, the Hunter 2 catheter was then advanced to the horizontal portion of the left uterine artery.
The orifice of the uterine artery on the left side was identified; however, the flow had been stopped by a previous embolization and no embolization was done.
The Hunter 2 catheter was then advanced over the Benson glidewire to the aortic arch. Under fluoroscopic vision the Terumo Glidewire was introduced into the right common iliac artery. Using road mapping techniques the angled glidewire was introduced into the internal right iliac artery and the catheter advanced.
The orifice of the right uterine artery was identified, again, it had been successfully embolized in a prior procedure. No embolization was necessary.
The tip of the catheter was then further withdrawn into the common iliac artery on the patient's right side where an arteriogram demonstrated clear flow to the external femoral artery and stasis within the uterine artery and no non-target embolization.
The catheter was then exchanged for an Omni Flush 5-French catheter which was inserted into the aorta. The pelvis was imaged again with a power injector using the same injection frequency of 10 cc of contrast per second for 2 seconds for a total of 20 cc of contrast. Angiography of the pelvis revealed stasis within the pelvic vessels and good flow within the other pelvic structures.
The Omni Flush catheter was then advanced to the level of the renal arteries. The image intensifier was placed at the pelvic rim and with power injection using 20 cc of contrast per second for 1.5 seconds for a total of 30 cc of contrast, search for an ovarian artery blood supply was done. The left ovarian artery arising approximately 3 cm distal to the renal arteries was identified and noted to be supplying the uterus. It was cannulated with an SMS-1 catheter and through that a microcatheter(Progreat) was advanced. Prior to embolization of the artery, the patient was given a 20 mg transarterial injection of Toradol. Embolization was performed with two vials of 200-500 micron PVA particles(Merit). Following embolization, the patient was given 5 cc of 1% buffered lidocaine for pain relief.
Also noted was a right ovarian artery. The patient's had been exposed to radiation for a considerable period and will be offered a second procedure to embolize the right ovarian artery in the future if needed.
A contrast injection was performed through the introducing sheath to verify the appropriate location for deployment of an arteriotomy closure device. An Angio-Seal arteriotomy closure device was then applied over the .035-inch glidewire and deployed successfully into the arteriotomy site. No bleeding and no hematomata were seen at the end of the application. Urine was clear, feet were warm, dorsalis pedis pulses were strong bilaterally. Pulse oximeter on the first right metatarsal read 100% oxygen saturation on room air. The patient left the procedure room in stable condition.
TOTAL FLUOROSCOPY TIME
16 minutes 20 seconds
TOTAL CONTRAST USED
160 cc of Visipaque