# Embolization - renal artery



## prabha (Aug 9, 2010)

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.


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## Hari Prasadh (Aug 22, 2010)

Would code 36299 instead of 50000 series codes

Harish, CPC, CCS


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## preserene (Aug 23, 2010)

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!!


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## dpeoples (Aug 24, 2010)

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]


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## boogiebowden (Sep 2, 2010)

*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!!!


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## dpeoples (Sep 3, 2010)

boogiebowden said:


> Here's my two cents:
> 
> 37204 yes-agreed
> 36247 yes-agreed
> ...



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


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## prabha (Sep 7, 2010)

Thanks all for your inputs.....


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