# Mesenteric Angiogram



## JenReyn99 (May 1, 2016)

These are still really confusing me! I'm still learning, but I have no resources and have had no training on when to use selective vs. non-selective codes, and which arteries are covered as first, second and third order. I've come a long way since I started working these, but still have a lot to learn. So any help with what codes would be for the following is greatly appreciated!

"....The right groin was prepped in usual sterile fashion and draped. A surgical timeout was performed. Anesthetize the soft tissues to 4 ml 1% lidocaine. I accessed the common femoral artery with a 21-guage micropuncture needle. 

Needle was exchanged over guidewire for a dilator which was then exchanged over guidewire for 6 French sheath. Using a 4 French Levin catheter I was able to catheterize the superior mesenteric artery. This revealed a replaced right hepatic artery. I do not see any active extravasation of contrast upon injection of the SMA. I then proceeded with catheterizing ther celiac trunk. 

Moderate localized the select trunk had difficulty placing a catheter into the vessel. I then placed an Omni Flush catheter into the aorta and performed an aortogram. This revealed the select trunk with stenotic at its origin. I then subsequently was able to catheterize the proximal select trunk with a variety of catheters including a Levin catheter and Cobra catheter however was unable to pass a catheter beyond stenosis. I attempted with a SOS catheter without success. I then catheterized the left common femoral artery from a contralateral approach and performed a Simmons 2 catheter. While I was able to catheterize the lateral celiac trunk was unable to seat the catheter beyond the stenotic segment. This precluded empiric embolization of the GDA. 

The catheters and wires removed and the sheath was sutured in place patient was discharged intensive care unit for supportive care. "

Seriously, I appreciate any insight and help. Thanks!


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## Jim Pawloski (May 5, 2016)

JenReyn99 said:


> These are still really confusing me! I'm still learning, but I have no resources and have had no training on when to use selective vs. non-selective codes, and which arteries are covered as first, second and third order. I've come a long way since I started working these, but still have a lot to learn. So any help with what codes would be for the following is greatly appreciated!
> 
> "....The right groin was prepped in usual sterile fashion and draped. A surgical timeout was performed. Anesthetize the soft tissues to 4 ml 1% lidocaine. I accessed the common femoral artery with a 21-guage micropuncture needle.
> 
> ...



Think of the aorta as a highway. When you get off the highway you take an exit ramp. A main branch of the aorta is a first order selective (exit ramp). When you come to the end of the ramp, you have to decide if your going right or left. Same thought of the second order selective.  So when you have to make a decision of what branch you are going, that is when you have a change in selective order. 
So for this case, I would bill 36245/ 75724 for the SMA, and 36245-XS and 75724-59 for the celiac artery.  Do not code for the embolization of the GDA as there is no documentation for it.
HTH,
Jim Pawloski, CIRCC


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## JenReyn99 (May 5, 2016)

This is very helpful information. Thank you! I also discovered Appendix L. I feel a little silly that I didn't know that was there, but it is a huge help. Thanks!


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## chembree (May 31, 2016)

Jim Pawloski said:


> Think of the aorta as a highway. When you get off the highway you take an exit ramp. A main branch of the aorta is a first order selective (exit ramp). When you come to the end of the ramp, you have to decide if your going right or left. Same thought of the second order selective.  So when you have to make a decision of what branch you are going, that is when you have a change in selective order.
> So for this case, I would bill 36245/ 75724 for the SMA, and 36245-XS and 75724-59 for the celiac artery.  Do not code for the embolization of the GDA as there is no documentation for it.
> HTH,
> Jim Pawloski, CIRCC




Hi Jim,

Why would you use 75724 vs. 75726 for the S&I portion of the SMA and Celiac?


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## Jim Pawloski (Jun 15, 2016)

chembree said:


> Hi Jim,
> 
> Why would you use 75724 vs. 75726 for the S&I portion of the SMA and Celiac?



Because my fat fingers hit the 4 instead of the 6. My error it should have been 75726.
Thanks,
Jim


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## chembree (Jun 20, 2016)

Thanks Jim. I know you know your stuff, so I knew there had to be a reason. I was second guessing myself.


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