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Embolization - renal artery

  1. Default Embolization - renal artery
    Exam Training Packages
    Please confirm my codes for the below procedure...

    37204
    36247
    36248
    50390
    75894-26
    75898-26
    75722-26
    75774-26
    75774-2659
    76942-2659.

    REALTIME ULTRASOUND GUIDED ACCESS OF A PATENT RIGHT COMMON FEMORAL
    ARTERY.
    ULTRASELECTIVE CATHETERIZATION OF THE RIGHT RENAL ARTERY.
    TRANSCATHETER EMBOLIZATION OF 2 DISTAL RIGHT RENAL ARTERIES.
    FOLLOWUP ANGIOGRAPHY FOLLOWING EMBOLIZATION.
    REAL-TIME ULTRASOUND GUIDED ACCESS OF THE RIGHT RENAL ARTERY
    ANEURYSM SAC USING A SUBCOSTAL PERCUTANEOUS TRANSRENAL APPROACH.
    VIA THIS APPROACH, EMBOLIZATION OF THE RIGHT RENAL ARTERY ANEURYSM
    SAC WAS PERFORMED USING MULTIPLE MICROCOILS AND GELFOAM SLURRY.

    82-year-old female with history of right renal artery aneurysm
    status post embolization 2 years ago now referred for a
    angiography and percutaneous intervention.

    Procedure:
    With the patient in the supine position, the right groin was
    prepped and draped in a sterile fashion. Intravenous antibiotics
    were administered. Under real-time ultrasound guidance, a 21-gauge
    needle was advanced into the right common femoral artery. A 5
    French vascular sheath was placed. A 4 French USL catheter was
    placed in the right renal artery and selective angiography was
    performed. Systemic anticoagulation was administered. Multiple
    aliquots of intra-arterial papaverine were administered.

    The segmental artery to the upper pole was selected and selective
    angiography was performed. Subsequently the distal most branch of
    the upper pole segmental artery was selected and the selective
    angiography was performed. This vessel was then treated with
    transcatheter embolization using embospheres (900-1200 ?: approx.
    1.25 cc) and a 4 mm Nestor microcoils. Postembolization
    angiography was performed.

    A second distal branch of the upper pole segmental artery was
    selected. This vessel had been treated with previous transcatheter
    embolization. A 3 French microcatheter was inserted into this
    vessel and transcatheter embolization was performed using
    (900-1200 ?: approx. 1.00 cc) and a 3 mm Nestor microcoil.
    Postembolization angiography was performed.

    Subsequently, transabdominal ultrasound examination of the right
    renal artery aneurysm demonstrated persistent flow. The patient's
    care was once again discussed with her son. The possibility of 13
    direct percutaneous puncture and embolization of the aneurysm was
    discussed. The increased risk of bleeding was also discussed. The
    son consented for percutaneous puncture and transneedle
    embolization.

    A sterile prep and drape of the right anterolateral abdomen was
    performed. Using real-time ultrasound guidance, a 21-gauge needle
    was advanced into the aneurysm sac via a trans-renal approach.
    Blood return was noted through the needle. Contrast was injected
    and the aneurysm sac was opacified. Subsequently multiple 20 mm
    and 30 mm diameter coils measuring 100 mm in length were deposited
    within the aneurysm sac. In addition 1500 units of thrombin in 1.5
    cc saline was injected into the aneurysm sac. Approximately 3 cc
    of Gelfoam slurry was also used to embolize the aneurysm sac.
    Gentle contrast injection via the needle demonstrated no antegrade
    flow in the aneurysm at this time.

    Post embolization right renal artery angiography was performed.

    The right groin sheath was removed and hemostasis was achieved
    with manual compression over the puncture site.

    Findings:
    The right renal artery is patent and demonstrates a large (3 cm)
    renal artery aneurysm in the region of the right upper pole. There
    is evidence of previous transcatheter coil embolization of distal
    branches of the right renal artery. Multiple collateral vessels
    are identified distal to these coils and continued to feed the
    aneurysm. Two feeding branches of the aneurysm originated from the
    segmental artery to the upper pole.

    Ultraselective of catheterization of the lateral most distal
    branch of the upper pole segmental artery was performed and
    demonstrates opacification of a branch that supplies some of the
    upper and lateral normal renal parenchyma. Transcatheter
    embolization was performed distal to this branch. Embolization was
    performed using embospheres and coils.

    Subsequently a second distal branch of the upper pole segmental
    artery was catheterized and an ultraselective fashion. This
    branch also demonstrated flow to the aneurysm via multiple
    tortuous vessels but also demonstrated coils within them. Despite
    the presence of these coils there is flow distal in these branches
    with subsequent reconstitution of the aneurysm. This vessel was
    treated with transcatheter embolization with embospheres and
    coils.

    Postembolization angiography demonstrates slowing of vessels
    supplying the aneurysm but persistent opacification of the
    aneurysm.

    At this time direct puncture of the aneurysm was discussed with
    the patient's son. The patient's son wished for our team to
    proceed with further intervention.

    Using real-time ultrasound guidance, a 21 gauge needle was
    directly passed into the aneurysm sac. Multiple vein of Galen
    microcoils were placed in the aneurysm. Gelfoam slurry and a small
    amount of thrombin was placed in the aneurysm to promote
    thrombosis.

    No further flow was demonstrated in the aneurysm with duplex
    imaging.

    Right renal angiography demonstrates no further opacification of
    branches supplying the aneurysm. There is preservation of flow to
    a distal branch of the upper pole segmental artery as well as mid
    and lower pole segmental arterial branches of the main right renal
    artery.

    IMPRESSION:
    Large (3 cm) renal artery aneurysm with supply from previously
    embolized branches of the distal segmental artery to the right
    upper pole.

    Ultrasound of catheterization and angiography of distal branches
    of the right upper pole segmental artery using particles and coils
    resulting in slowing of antegrade flow in the aneurysm.

    Real-time ultrasound guided access of the aneurysm sac via a
    transabdominal approach.

    Via this tract aneurysm sac access, embolization of the aneurysm
    sac was performed using coils and Gelfoam as described above.
    Last edited by prabha; 08-09-2010 at 04:28 AM.
    Prabha CPC

  2. #2
    Location
    United Aram Emirates
    Posts
    5
    Default
    Would code 36299 instead of 50000 series codes

    Harish, CPC, CCS

  3. Default
    Renal artery aneurysm and embolyzation!!
    Oh such a complicated riddle just as the procedures complicated! I know I fail in this test. But just wish to give a trial!!!
    Renal artery catheter placement in the vascular family is first order. The renal artery divides into dedicated branch of for each of the five segments of the kidney, though they do not anastomose with one another. The renal artery is not given more than the first order, though, for coding purposes.
    So the code is 36245 for renal artery placement. ( first order selective placement in the vascular tree)
    Real time US service: 76936+76937,
    Angiography: 75894 and 75898 with modifier -26 and 59 appended to them.
    This is just my fast track openion with a more complex procedure. I too need to know the correct coding for this with all its rationales.
    Thank you Prabha for the great riddle!!

  4. #4
    Location
    Birmingham, Alabama
    Posts
    889
    Default
    see my repsonses below....
    HTH


    QUOTE=prabha;121835]Please confirm my codes for the below procedure...

    37204 yes
    36247 yes
    36248 yes
    50390 no, I would use 36299
    75894-26 yes
    75898-26 yes
    75722-26 yes
    75774-26 yes
    75774-2659 yes
    76942-2659. no, I would use 76937 instead.

    REALTIME ULTRASOUND GUIDED ACCESS OF A PATENT RIGHT COMMON FEMORAL
    ARTERY.
    ULTRASELECTIVE CATHETERIZATION OF THE RIGHT RENAL ARTERY.
    TRANSCATHETER EMBOLIZATION OF 2 DISTAL RIGHT RENAL ARTERIES.
    FOLLOWUP ANGIOGRAPHY FOLLOWING EMBOLIZATION.
    REAL-TIME ULTRASOUND GUIDED ACCESS OF THE RIGHT RENAL ARTERY
    ANEURYSM SAC USING A SUBCOSTAL PERCUTANEOUS TRANSRENAL APPROACH.
    VIA THIS APPROACH, EMBOLIZATION OF THE RIGHT RENAL ARTERY ANEURYSM
    SAC WAS PERFORMED USING MULTIPLE MICROCOILS AND GELFOAM SLURRY.

    82-year-old female with history of right renal artery aneurysm
    status post embolization 2 years ago now referred for a
    angiography and percutaneous intervention.

    Procedure:
    With the patient in the supine position, the right groin was
    prepped and draped in a sterile fashion. Intravenous antibiotics
    were administered. Under real-time ultrasound guidance, a 21-gauge
    needle was advanced into the right common femoral artery. A 5
    French vascular sheath was placed. A 4 French USL catheter was
    placed in the right renal artery and selective angiography was
    performed. Systemic anticoagulation was administered. Multiple
    aliquots of intra-arterial papaverine were administered.

    The segmental artery to the upper pole was selected and selective
    angiography was performed. Subsequently the distal most branch of
    the upper pole segmental artery was selected and the selective
    angiography was performed. This vessel was then treated with
    transcatheter embolization using embospheres (900-1200 ?: approx.
    1.25 cc) and a 4 mm Nestor microcoils. Postembolization
    angiography was performed.

    A second distal branch of the upper pole segmental artery was
    selected. This vessel had been treated with previous transcatheter
    embolization. A 3 French microcatheter was inserted into this
    vessel and transcatheter embolization was performed using
    (900-1200 ?: approx. 1.00 cc) and a 3 mm Nestor microcoil.
    Postembolization angiography was performed.

    Subsequently, transabdominal ultrasound examination of the right
    renal artery aneurysm demonstrated persistent flow. The patient's
    care was once again discussed with her son. The possibility of 13
    direct percutaneous puncture and embolization of the aneurysm was
    discussed. The increased risk of bleeding was also discussed. The
    son consented for percutaneous puncture and transneedle
    embolization.

    A sterile prep and drape of the right anterolateral abdomen was
    performed. Using real-time ultrasound guidance, a 21-gauge needle
    was advanced into the aneurysm sac via a trans-renal approach.
    Blood return was noted through the needle. Contrast was injected
    and the aneurysm sac was opacified. Subsequently multiple 20 mm
    and 30 mm diameter coils measuring 100 mm in length were deposited
    within the aneurysm sac. In addition 1500 units of thrombin in 1.5
    cc saline was injected into the aneurysm sac. Approximately 3 cc
    of Gelfoam slurry was also used to embolize the aneurysm sac.
    Gentle contrast injection via the needle demonstrated no antegrade
    flow in the aneurysm at this time.

    Post embolization right renal artery angiography was performed.

    The right groin sheath was removed and hemostasis was achieved
    with manual compression over the puncture site.

    Findings:
    The right renal artery is patent and demonstrates a large (3 cm)
    renal artery aneurysm in the region of the right upper pole. There
    is evidence of previous transcatheter coil embolization of distal
    branches of the right renal artery. Multiple collateral vessels
    are identified distal to these coils and continued to feed the
    aneurysm. Two feeding branches of the aneurysm originated from the
    segmental artery to the upper pole.

    Ultraselective of catheterization of the lateral most distal
    branch of the upper pole segmental artery was performed and
    demonstrates opacification of a branch that supplies some of the
    upper and lateral normal renal parenchyma. Transcatheter
    embolization was performed distal to this branch. Embolization was
    performed using embospheres and coils.

    Subsequently a second distal branch of the upper pole segmental
    artery was catheterized and an ultraselective fashion. This
    branch also demonstrated flow to the aneurysm via multiple
    tortuous vessels but also demonstrated coils within them. Despite
    the presence of these coils there is flow distal in these branches
    with subsequent reconstitution of the aneurysm. This vessel was
    treated with transcatheter embolization with embospheres and
    coils.

    Postembolization angiography demonstrates slowing of vessels
    supplying the aneurysm but persistent opacification of the
    aneurysm.

    At this time direct puncture of the aneurysm was discussed with
    the patient's son. The patient's son wished for our team to
    proceed with further intervention.

    Using real-time ultrasound guidance, a 21 gauge needle was
    directly passed into the aneurysm sac. Multiple vein of Galen
    microcoils were placed in the aneurysm. Gelfoam slurry and a small
    amount of thrombin was placed in the aneurysm to promote
    thrombosis.

    No further flow was demonstrated in the aneurysm with duplex
    imaging.

    Right renal angiography demonstrates no further opacification of
    branches supplying the aneurysm. There is preservation of flow to
    a distal branch of the upper pole segmental artery as well as mid
    and lower pole segmental arterial branches of the main right renal
    artery.

    IMPRESSION:
    Large (3 cm) renal artery aneurysm with supply from previously
    embolized branches of the distal segmental artery to the right
    upper pole.

    Ultrasound of catheterization and angiography of distal branches
    of the right upper pole segmental artery using particles and coils
    resulting in slowing of antegrade flow in the aneurysm.

    Real-time ultrasound guided access of the aneurysm sac via a
    transabdominal approach.

    Via this tract aneurysm sac access, embolization of the aneurysm
    sac was performed using coils and Gelfoam as described above.[/QUOTE]
    Danny L. Peoples
    CIRCC,CPC

  5. Default same operative field
    Here's my two cents:

    37204 yes-agreed
    36247 yes-agreed
    36248 yes-agreed
    50390 no, I would use 36299-not sure what either of these codes correlate to in the OP note. If they are in reference to the second attempt at embolization via the needle into the aneurysm sac, I would not code anything additional. That was merely the route. You are still treating the same operative field and you can only bill embolization per operative field.
    75894-26 yes-agreed
    75898-26 yes-agreed
    75722-26 yes-agreed
    75774-26 yes-agreed
    75774-2659 yes-agreed (side note, my carrier would want this line item billed since it's an addtional code, rather than two lines with a -59...but however your carrier accepts, only you know through trial and error...bottom line, 2 of these should be billed =) )
    76942-2659. no, I would use 76937 instead.-I wouldn't billed 76942 because that code isn't to be reported with any S & I codes and I wouldn't bill 76937 because I don't see anything referencing vessel patency and/or mention of an image being stored which is necessary to bill for the 76937.

    Hope this was helpful! Best of luck!!!

  6. #6
    Location
    Birmingham, Alabama
    Posts
    889
    Default
    Quote Originally Posted by boogiebowden View Post
    Here's my two cents:

    37204 yes-agreed
    36247 yes-agreed
    36248 yes-agreed
    50390 no, I would use 36299-not sure what either of these codes correlate to in the OP note. If they are in reference to the second attempt at embolization via the needle into the aneurysm sac, I would not code anything additional. That was merely the route. You are still treating the same operative field and you can only bill embolization per operative field.
    75894-26 yes-agreed
    75898-26 yes-agreed
    75722-26 yes-agreed
    75774-26 yes-agreed
    75774-2659 yes-agreed (side note, my carrier would want this line item billed since it's an addtional code, rather than two lines with a -59...but however your carrier accepts, only you know through trial and error...bottom line, 2 of these should be billed =) )
    76942-2659. no, I would use 76937 instead.-I wouldn't billed 76942 because that code isn't to be reported with any S & I codes and I wouldn't bill 76937 because I don't see anything referencing vessel patency and/or mention of an image being stored which is necessary to bill for the 76937.

    Hope this was helpful! Best of luck!!!
    cleverly hidden at the beginning of the report are these words
    "REALTIME ULTRASOUND GUIDED ACCESS OF A PATENT RIGHT COMMON FEMORAL
    ARTERY"

    however, I do agree that a permanent image is needed to code 76937, so I would cofirm with the physicians that one is being generated.

    HTH
    Danny L. Peoples
    CIRCC,CPC

  7. Default
    Thanks all for your inputs.....
    Prabha CPC

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