need help with spinal angio coding please

bhargavi

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Middletown, DE
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Procedures​

SPINAL ANGIOGRAPHY
Pre Procedure Diagnosis​

Q27.39

Link to Procedure Log​

Indications




Arteriovenous malformation, other site [Q27.39 (ICD-10-CM)]​

Conclusion





Report for: Transfemoral approach diagnostic spinal angiogram for possible AVM
Date of procedure: May 12, 2020
Reason for angiogram: Concern for spinal dural fistula or AVM
Brief history: Patient with complicated medical history back pain status post thoracic surgery, uncontrolled HTN, DM, HLD, history of smoking who had surgery for her back issues and during surgery there was concern for vascular abnormality spinal angiogram was requested by neurosurgery to further identify any vascular abnormality in her spine.

Informed consent: The procedure was explained to the patient in layman terms. Multiple images and diagrams were used to explain the procedure. The procedure which includes but not limited to groin hematoma, retroperitoneal hematoma, contrast neohropathy, Major and minor stroke, vascular dissection and death was explained to the patients in layman terms. All questions were appropriately answered, patient and patient family elected to have the above procedure performed.

Anesthesia: conscious sedation: Patient was placed on continuous hemodynamic monitoring and direct face to face observation was done during the procedure for over 60 plus minutes. Conscious sedation administration using 3 mg Versed and 125mcg fentanyl was done. Continue monitoring and direct management of conscious sedation was done by me during whole procedure and post procedure
Procedures performed:​


    1. Right femoral arteriotomy.

    2. Conscious sedation for duration of 60 minutes with direct face-to-face observation and monitoring of the patient.

    3. Lumbar aortogram using pigtail catheter

    4. Aortic arch aortogram using pigtail catheter

    5. Catheterization and angiogram of thoracic and lumbar spinal arteries at the following levels

    6. Catheterization and angiogram of bilateral T3 segmental arteries

    7. Catheterization angiogram of bilateral T4 segmental arteries

    8. Catheterization angiogram of bilateral T6 segmental arteries

    9. Catheterization angiogram of bilateral T7 segmental arteries

    10. Catheterization angiogram of left T8 segmental artery

    11. Catheterization angiogram of left T9 segmental artery

    12. Catheterization and angiogram of bilateral T10 segmental artery

    13. Catheterization and angiogram of T12 bilateral segmental arteries

    14. Catheterization and angiogram of left lumbar segmental artery at L1

    15. Catheterization angiogram of bilateral lumbar segmental artery at L2

    16. Catheterization angiogram of bilateral lumbar segmental artery at L4.

    17. Catheterization and angiogram of left subclavian artery

    18. Right femoral artery angiogram

    19. Manual compression of right groin arteriotomy site

Description of procedure: patient was brought to angio suite and identified using multiple patient identifiers. Time out was performed by entire team. Patient was placed in supine position on angiography table and bilateral ground and right wrist was cleaned using beta fine solution. Sterile drape was applied. Right femoral artery was palpated and under ultrasound 5 French sheath was placed using micro puncture kit and modified Seldinger technique. This was sutured and continuously flushed with pressurized heroism saline. A 5 French pigtail catheter was used for lumbar aortogram and thoracic aortogram.  After that Mikelson catheter was used for catheterization and angiogram of lumbar and lower thoracic segmental arteries .Cobra catheter was used for catheterization angiogram of upper thoracic arteries .along with left subclavian artery .catheters were continuously flushed with heparinized swine and was then navigated over 0.035 guidewire up to arch of aorta where it was reconstituted and following blood vessels were catheterized.  Letter was taken the angiogram was analyzed and subsequently removed from the body without any incident. Patient was examined without any neurological deficits and femoral sheath was removed and manual compression was applied at the site of arteriotomy.  Patient had a mild hematoma in the groin size which was compressed and no further complication was identified.​
Disposition- patient sent back to ambulatory surgery care for further monitoring
Interpretation :

Lumbar segmental arteries catheterization and interpretation-using Mickelson catheter lumbar segmental arteries at the level of L1, L2, L4​

Left L1 segmental artery catheterization and angiogram revealed normal-appearing segmental artery.  The segmental artery can be seen dividing into spinal artery which further divides into anterior and posterior radicular artery.  Spinal artery along with anterior and posterior pedicle artery at the L1 level peers normal.  No evidence of any abnormal vasculature seen no evidence of any early venous filling or any tortuous blood vessel identified.

Bilateral L2 segmental artery catheterization revealed normal spinal artery and its branches of anterior and posterior radicular artery.  Posterior spinal artery can also be very seen in the angiogram.  No evidence of any abnormal vasculature early filling or tortuous blood vessel seen

Bilateral L4 segmental artery catheterization with normal-appearing segmental artery along with normal-appearing spinal artery and its radicular anterior and posterior branches.

Lumbar aorta also appears normal.

Lumbar aortogram reveals bilateral L1, L2, L3-L4-L5 segmental arteries along with normal-appearing radicular branches.  No evidence of any early venous filling any tortuous blood vessel or any other vascular malformation seen.
Bilateral iliac artery appears normal.  Also on the aortogram bilateral renal artery appears normal in shape and caliber.  No evidence of any renal artery stenosis seen.
Thoracic segmental arteries catheterization and angiogram interpretation​

Thoracic segmental artery catheterization was done using Cobra catheter in the upper thoracic level and Mickelson catheter in the lower thoracic level segmental arteries.

Bilateral intercostal arteries at T3, T4, T6 and T7 level appears normal with.  Normal spinal branches of the segmental artery.  The segmental arteries branches into posterior artery and medullary artery with all appears normal.

Left T8,T9 and bilateral T11 and T12 intercostal artery along with spinal segmental artery and anterior and posterior medullary artery appears normal

No abnormal vein or any tortuous blood vessels seen.  No evidence of any dural artery fistula or AVM.

Left subclavian artery angiogram and catheterization showed normal-appearing left subclavian artery.  The origin of vertebral artery appears normal.  The thyrocervical trunk and intercostal artery along internal mammary artery all appears normal.  The distal subclavian artery appears normal without any evidence of stenosis or any other vascular malformation.

The aortic arch angiogram using pigtail catheter shows normal grade 2 aortic arch with normal-appearing origin of subclavian artery, left common carotid artery and brachiocephalic artery.  No evidence of any early venous filling or any other vascular malformation identified.  Bilateral vertebral artery origin appears normal.


Right common femoral artery angiogram- Right CFA angiogram demonstrate normal appearing right CFA proximally with normal bifurcation. The site of arteriotomy appears well above bifurcation of CFA.​

Impression:
1.  Angiogram of spine appears to show no evidence of any spinal dural fistula or any AVM at the cervical, thoracic or lumbar spine region.







thank you in advance. I have never code spinal or any neuro cases. this is the first time our lab started performing neuro cases otherwise I work in cath and ep lab which I code for those procedures



 

ernist8489

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We would code this case as follows-
36225-LT, 36215-XS x 14, 36245-50-XS x2,
36245-XS-LT, 75705 XS x19,
99152, 99153x3.

1).Selective Left Subclavian Angiogram-36225-LT.
2).Selective Thoracic injections Bilateral T3,T4,T6,T7, Left T8, Left T9, Bilateral T10,T12.- 36215-XS x 14.
3).Selective Lumbar injections
L1- 36245-XS-LT,
L2,L4- 36245-50-XS x 2
4).Selective Spinal Angiography for all 19 spinal arteries selected- 75705-XS x 19.
5). Moderate conscious sedation - 60 minutes = 4 units. 99152, 99153x3.

I love these cases. So first off you must always remember that Medicare does not allow for the reporting of bilateral modifier 50 for above the diaphragm selective catheterization codes (36215-36218). And they do allow for modifier 50 for below the diaphragm selective codes (36245-36248).
So for selective spinal angiography that means Cervical and Thoracic regions your looking at 36215-36218 and coding each vessel as a seperate unit (14 thoracic arteries selected so we one unit for each artery selected. 2 units for each bilateral level plus the single left t8 is 1 Unit and 1 t9 =14 total so for the Thoracic arteries all branching off aorta make them all 1st order selections so we Code
36215-XS x14. (XS modifier to delineate that they are seperate and distinct vessels for each and 14 for the units.)
As for the lumbar/sacral we use (36245-36248) these can be tricky, yet simple.
So we have Bilateral selective injections at L2, L4 so we Code as 36245-50-XS x2. Two bilateral units because two levels selected Bilaterally and the XS for unbundling the seperate families. Now for the left L1 we code that as seperate and distinct - 36245-XS-LT .
For the Left subclavian selection because the left subclavian branches directly off of the aorta the Thoracic aortography bundles into the subclavian angiogram, documentation states vertebral circulation was viewed thus we assign code 36225, for the subclav angio.
As for the spinal angiography, we have 19 selective injections between the 14 thoracic intercostals and 5 lumbar thus we report 75705 XS x 19.
And Moderate conscious sedation we have an easy 60 minutes so 99152
99153x3.
 
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