You need to bill for the bilateral catheter choleangiogram and biliary tube exchanges.36245
Can we code the above set of codes for the vascular intervention(alone) done in the below report or do we need to add any other CPT
History: 80 year old male with Klatskin tumor, status post
bilateral percutaneous biliary drainage in June, presents with
bloody bilious drainage from the left-sided catheter. In
addition, patient has been lethargic and has been losing weight.
The patient was hypoglycemic upon initial evaluation and was
treated with D50 IV prior to the procedure. He is referred for
emergent cholangiogram, possible biliary catheter exchange and
possible mesenteric artery and embolization.
Procedure in brief: Bilateral catheter cholangiogram, bilateral
biliary drainage catheter exchange, selective mesenteric angiogram
Immediate Complications: Chills and rigors
Procedure and Findings:
With the patient in the supine position the upper abdomen and both
biliary catheters were prepped and draped in the usual sterile
fashion. The right biliary catheter was aspirated. Contrast
injection through the catheter demonstrates advancement of the
catheter into the strictured portion of the bile duct. Upon
partial withdrawal of the catheter, opacification of dilated right
hepatic ducts is noted. The catheter was then cut and exchanged
for a new 8-French multi-side hole biliary drainage catheter was
most proximal sideholes were positioned draining these ducts. The
catheter was sutured into place and left external drainage via a
bedside drainage bag.
The left-sided catheter was then aspirated. Serosanguineous
biliary drainage was noted. Contrast injection through the
catheter demonstrates small filling defects consistent with clots
within the biliary tree. The catheter was then exchanged over a
stiff glide wire for a 6-French vascular sheath. Contrast
injection during pullback of the sheath along the catheter tract
demonstrates opacification of a presumed left hepatic artery or
portal vein branch. The sheath was then replaced along the tract
to tamponade the blood vessel.
The right groin region was then prepped and draped in the usual
sterile fashion in preparation for mesenteric angiography. The
right common femoral artery was accessed via single wall puncture
with a 21-gauge micropuncture needle. A 5-French vascular sheath
was placed via this puncture site. A 5-French Omni flush catheter
was advanced through the sheath and positioned within the
abdominal aorta at the level of the mesenteric vessel origins.
Contrast injection with digital imaging of the abdominal aorta in
the frontal projection was performed. The catheter was exchanged
for a Sos II selective catheter and the superior mesenteric artery
origin was selected. Contrast injection with digital imaging in
the frontal, oblique and lateral projections was performed. A
microcatheter was then advanced through the outer catheter in an
attempt to cannulate the proximal SMA branch feeding celiac artery
branches. A proximal upgoing branch was cannulated and
angiography in the frontal projection was performed.
These images demonstrate patency of the abdominal aorta. The
superior mesenteric artery is widely patent. The celiac artery is
presumably occluded at its origin. It is unclear if this
represents a congenital or pathologic lesion. Prominent
pancreaticoduodenal/gastroduodenal arteries reconstitute the
celiac artery branches. The right and left hepatic and splenic
arteries are patent. No gross contrast extravasation from left
hepatic artery branches is identified. The main portal vein and
the right and left portal veins are patent.
The patient began experiencing chills and rigors. 25 mg of
Demerol and Tylenol suppositories were administered. It was
decided to terminate the procedure at this time. A 10-French
biliary drainage catheter was replaced across the left biliary
tree. No bleeding was noted along the track. Left biliary tree
was then irrigated and flushed with sterile saline solution. The
catheter was sutured into place and left to J-P drainage. The
patient was transferred to the intensive care unit for further
Impression: Catheter cholangiogram demonstrates a mildly dilated
left biliary system with small intralumenal filling defects
consistent with clots. Contrast injection during pullback of
sheath along the catheter tract demonstrates communication of the
biliary tree with a presumed left hepatic artery branch. The
bleeding vessel was tamponaded with the catheter/sheath in place.
Selective mesenteric angiogram demonstrates patency of the
superior mesenteric artery with occlusion of the celiac artery at
its origin. Prominent pancreaticoduodenal/gastroduodenal arteries
reconstitute the celiac artery branches. The right and left
hepatic arteries are patent. No gross contrast extravasation is
seen from left hepatic artery branches.
In view of patient development of chills and rigors, the procedure
was terminated prior to further angiographic evaluation. New
8-French and a 10-French biliary drains were left across the right
and left biliary systems extending into the bowel, respectively.
No bleeding was noted along each respective catheter tract. The
left biliary tree was vigorously irrigated and clots were
aspirated through the catheter until clear. The patient is to be
observed in the medical intensive care unit overnight. Repeated
angiographic evaluation with possible embolization may be
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