Question Transarterial Chemoembolization

Stanford, KY
Best answers
I am fairly new to coding for interventional radiology, and I'm struggling with this specific case for the professional coding.

I am struggling with whether or not it is appropriate to bill for the angiographies(75726/ add-on 75774) that were performed during the procedure. The provider wanted to bill for 6 times, but did not know it had an MUE of 3. In my review of his documentation I suggested to bill 75726 only for the celiac artery with a modifier because it is a column 2 CPT for 37243 which was performed on the segment 2 artery. CPT 37243 is inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; therefore, I did not justify billing cpt 75726 for the hepatic, seg 4B, seg 4A, seg 3, and seg 2 arteries.

I was further advised that 75726 is billable only if there was not a prior angiography performed, and there was not.

So, can someone please advise me on the following..:
  1. Is the selection of codes 37243, 36247 x2, 36248 x4, 76937 correct?
  2. Should I bill for the angiography/how many times? Really need help understanding this piece..

1) Selective visceral arteriography
2) Transarterial chemoembolization

Contrast: 75 mL Isovue intraarterial
Fluoroscopy time: 79.5 minutes pulsed

Medications: Please refer to anesthesia record for medications administered case

Indication: Hepatocellular carcinoma

Procedure: Using real time ultrasound guidance the right common femoral artery was accessed with a micropuncture set. Over a wire this was upsized to a long 6-French sheath positioned in the abdominal aorta. Through this access, selective catheterization of the celiac artery was performed followed diagnostic angiography. Based on these results, selective catheterization of the left hepatic artery was then performed using a micro catheter and wire and further diagnostic arteriography carried out.

Based on these findings further sub selective catheterization with a micro wire was performed of the segment 4B artery. This was followed with selective catheterization of the segment 4A artery. This was followed with selective catheterization of the segment 3 artery. Ultimately selective catheterization of the segment 2 artery was performed. Based on these findings, extensive attempts were performed with different micro wire and micro catheter combinations to selectively catheterize the sub selective branch off of the segment to artery supplying the targeted lesion.

Based on these attempts, the decision was made to perform chemo embolization in the segment 2 artery. Under fluoroscopic visualization, the chemoembolic mixture was then delivered, 10 % total dose using 100-300 micron Embospheres combined with Liopidol. Post embolization selective arteriography was performed in each of the treated vessels. The catheter and sheath were then removed and hemostasis was achieved by 6F angioseal and manual compression.

This procedure took more than twice the usual time, an unusually large amount of materials, and required a very high level of technical expertise and skill.

Findings: Patent and compressible right common femoral artery. The celiac artery is patent. The left hepatic artery is patent. The segment 4A, 4B and 3 arteries are patient without opacification of the target lesion.

The segment 2 artery is patient.
A small branch vessel off of the proximal aspect of the segment 2 artery supplies the target tumor which has arterial enhancement.

Despite extensive efforts using multiple wire and catheter combinations, resulting is lost selective catheterization, requiring re-selective catheterization, this selective catheterization of the segment 2 branch to the tumor was unable to be achieved.

Embolization of the segment 2 artery resulted in opacification and tumor staining of the target lesion, as well as
aspects of segment 2 of the liver.

Thanks in advance!!
I would code this 37243, 36247, 36248 x 4, 75726, 75774 x 2, 76937. 36247 can only be coded once, angios were done on the celiac, left hepatic. The subselective catheterizations does not say if an angiogram was done, and most probably roadmapping.