pre-SIR-Spheres mapping procedure

AgnieszkaMarek

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Glesns Falls, NY
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Asking for advice in this scenario;:)

PROCEDURE:
* Selective angiography of the superior mesenteric, celiac and left
gastric arteries.
* Superselective angiography of the right and left phrenic artery.
* Superselective angiography of left hepatic artery, right hepatic
artery, 5/8 hepatic artery and subsegmental branches.
* Injection of Tc-99m-MAA into the left hepatic artery, and
subsegmental segment 8 hepatic arteries.
* Closure of arteriotomy with Perclose device.

TECHNIQUE:
The risks, benefits, and alternatives of visceral angiography and
embolization were discussed with the patient, and informed written
consent was obtained. The patient was brought to the angiography
suite, and the right groin was prepped and draped in the usual sterile
fashion. All elements of maximal sterile barrier technique were
followed including cap and mask, sterile gown, sterile gloves, large
sterile sheet, hand hygiene and 2% chlorhexidine for cutaneous
antisepsis. Sterile ultrasound probe cover and sterile gel was used.

After local anesthesia with 1% lidocaine, the right common femoral
artery was accessed with a 4-French micropuncture set and exchanged
for a 5-French sheath over a 0.035 inch 3 J-wire. A 5-French glide C2
catheter was directed to the aortic bifurcation, contralateral iliac
artery was selected. Next, Mickelson reverse-curve catheter was
performed over the wire. Left and right subcostal, left and right
phrenic artery was subselected or by angiography. In addition, left
gastric artery was subselected followed by angiography.

Next, right phrenic artery was subselected in coaxial fashion with a
microcatheter microwire, followed by superselective angiography. No
tumor blush/parasitic blood supply identified.

Next, the Mickelson reverse curve catheter was exchanged for a glide
C2 catheter. SMA and celiac was subselected followed by angiography.

Next, with a combination of Glidewire and C2 catheter, common hepatic
artery was subselected, followed by angiography.

Next, the left hepatic artery was subselected with a combination of
microcatheter microwire in coaxial fashion, followed by superselective
angiography. MAA particles was deposited in the left hepatic artery.


Next, right hepatic artery, subsegmental segment 7, and segment 8 was
subselected. There are significant vasospasm at the subsegmental
segment 8 branches, which was treated with intra-arterial
nitroglycerin. Next, and IMA particles was deposited in the
subsegmental segment 8 branches.

Catheters were removed. After angiographically confirming a right
common femoral artery puncture, the introducer sheath was exchanged
for an Perclose Device. Arteriotomy was then closed with the Perclose
closure Device. Hemostasis was obtained with 60 seconds of manual
compression. The patient tolerated the procedure well without
immediate complication and was transported to Nuclear Medicine for
further imaging.


FINDINGS/IMPRESSION:
* Selective angiography of the superior mesenteric, celiac and left
gastric arteries. Celiac branch into common hepatic and splenic.
Patent SMA, prominent first mid colic branch. Replaced left gastric
artery from aorta, no tumor feeding collaterals.
* Distal aortogram, high bifurcation of the abdominal aorta at the
level of L3.
* Superselective angiography of the right and left phrenic artery,
bilateral subcostal arteries. Superselective angiography of the distal
right phrenic artery near the diaphragmatic dome. No tumor feeding
collaterals/parasitic supply.
* Superselective angiography of left hepatic artery, right hepatic
artery, 5/8 hepatic artery and subsegmental branches.
* Injection of Tc-99m-MAA into the left hepatic artery, and

I am thinking of 36247;36248;75726;75774 ??? I feel like I am missing something.+
 

ernist8489

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The correct codes for this case are:
37242, 36247, 36247-XS, 36248, 36248, 36245-XS, 75726, 75774x4.

Sweet Case! These are fun but challenging.
1st and foremost The procedure performed was an arterial Embolization
37242.
With a multitude of selective and supraselective Angiograms. We code 37241 for the hepatic arterial Embolization. We then code 36247, 36248 for the right and left hepatic selections (2nd, or 3rd Order(seperate arterial branches same family).
36247-XS,36248 for (Right and Left phrenic selections.)
36245-XS for the 1st order Superior Mesenteric selection (No documentation that the selection went any further then the SMA) The SMA,IMA and Celiac Trunk are 3 seperate families and are codes seperately as applicable.
We code 75726 for the initial portion of the visceral angiogram which bundles the Aortogram. Finally we code 75774x4 1 Unit per each seperate selective angiogram after the first.
Hope this helps.! Awesome case.
Hit me up if you ever have any cases you need assistance with!

Erik Brown, CIRCC,CPC
 
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