# embolization help--new to me



## Tmatthews (Jun 3, 2015)

Please help!
Dr Reported
36222x1
36224x1
36226x1
75894
36200

I think:
36224
36226
61624
75894
75898x7


ICD Codes / Adm.Diagnosis: 437.3  437.3 / Cerebral aneurysm, nonruptured   

Cerebral aneurysm, nonruptur

Examination:  XA CAROTID CRBRL W CATH LT  - 

Accession No:  

Reason:  cerebral aneurysm





REPORT:

CLINICAL INDICATION:  Left anterior cerebral artery aneurysm for  

endovascular treatment.



OPERATORS:  



CONTROL ANGIOGRAMS:  7  



COMPLICATIONS:  None.  



GENERAL ANESTHESIA: Pre-procedure evaluation confirmed that the patient was  

an appropriate candidate for general anesthesia. Adequate anesthesia was  

maintained during the entire procedure by the anesthesia team. Vital signs  

and pulse oximetry were monitored and recorded by the anesthetist throughout  

the procedure and the recovery period. The flow sheet was placed in the  

medical record including the medications and dosages used. No immediate  

anesthesia related complications were noted.



PRE-PROCEDURE: The patient was seen and examined. The chart and images were  

reviewed. I had a lengthy discussion with the patient and/or their family  

regarding the disease process, as well as potential treatment options, which  

include medical management, surgical treatment, or endovascular treatment.  

The risks, benefits, and alternatives to the procedure were explained to the  

patient and/or the family, and written informed consent was obtained.  



PROCEDURE: A Time-Out was performed prior to the procedure to confirm the  

patient's identity and the appropriate procedure. The patient was placed  

supine on the angiographic table, and the right groin was prepped and draped  

in the usual sterile manner. Using a 5 French micropuncture set, the right  

common femoral artery was punctured and cannulated, and a 6 French arterial  

sheath was placed over a guidewire. The sheath was attached to continuous  

heparinized saline flush.  A catheter was placed through the sheath and  

advanced over a Terumo guidewire into the aortic arch.



Selective catheterization of the following blood vessels was performed (see  

below). At the end of the procedure, hemostasis was achieved. Hemostasis was  

achieved through placement of a Mynx closure device. Following hemostasis,  

with no hematoma, the site was cleaned and dressed with sterile dressing.  

Intravenous heparin was intermittently administered throughout the  

procedure, monitored with serial ACT measurements, with the ACT maintained  

at 250-300. The heparin was not reversed following the procedure.



DIAGNOSTIC ARTERIOGRAPHY AND SUPERVISION AND INTERPRETATION OF DIAGNOSTIC  

ARTERIOGRAMS:



LEFT COMMON CAROTID ARTERY:  The catheter was used to select the left common  

carotid artery. DSA in the AP and lateral views of the cervical region was  

performed. The imaged common, internal, and external carotid arteries are  

normal in caliber and contour. The carotid bifurcation is widely patent.



LEFT INTERNAL CAROTID ARTERY:  The catheter was advanced into the left  

internal carotid artery.  DSA in the AP, lateral, and oblique views of the  

intracranial circulation were performed.  The intracranial segments of the  

left internal carotid artery are normal in contour and caliber. The middle  

cerebral artery and its branch vessels are normal in caliber and contour.  

The anterior cerebral artery and its branch vessels are normal in caliber.  

There is a saccular aneurysm arising from the left anterior cerebral artery  

at the junction of the pericallosal and callosomarginal branches, measuring  

3.6 x 3.7 x 4.1 mm, with a 2.9 mm neck, projecting anteriorly, with a small  

(1.4 x 1.0 mm) bleb arising from the anterior wall and the anterior internal  

frontal branch arising from the aneurysm base. The anterior communicating  

artery does not opacify from this injection. Dynamic imaging demonstrates a  

normal capillary phase. The intracranial venous structures opacify  

appropriately and appear patent.



RIGHT EXTERNAL ILIAC ARTERY: The sheath was withdrawn into the right  

external iliac artery. DSA in the RAO and lateral views of the right  

iliofemoral arterial system was performed via injection through the sheath.  

The imaged iliofemoral arterial system is widely patent. The angiogram  

demonstrated conditions amenable to closure device deployment.  



SUPERSELECTIVE ARTERIOGRAPHY, EMBOLIZATION, AND FOLLOWUP ANGIOGRAMS;  

SUPERVISION AND INTERPRETATION OF SUPERSELECTIVE ARTERIOGRAPHY,  

EMBOLIZATION, AND FOLLOWUP ANGIOGRAMS:



EMBOLIZATION:  The 6 French guiding catheter was placed into the cervical  

left internal carotid artery over a guidewire.  A microcatheter was advanced  

over a microguidewire into the left anterior cerebral artery aneurysm sac  

using roadmap guidance.   



Attempts at embolization of the aneurysm were performed. An initial attempt  

was made with a Target Soft 4 mm x 8 cm coil, with coil material  

consistently and repetitively herniating into the parent vessel. Therefore,  

this coil was removed. Subsequently, attempts were made with a Hypersoft 3D  

3.5 mm x 5 cm coil and a Target Ultra Soft 3.5 mm x 8 cm coil, with coil  

material consistently and repetitively herniating into the parent vessel.  

Therefore, these coils were removed. A control angiogram (#1) was done prior  

to removal of the last coil, documenting the significant coil herniation  

into the parent vessel.



Treatment of the aneurysm was then performed using stent-assisted coil  

embolization. A Prowler select plus microcatheter was advanced into the left  

anterior cerebral artery over a microguidewire, and an Enterprise 4.5 x 14  

mm stent was deployed under continuous fluoroscopic surveillance and roadmap  

guidance. A control angiogram (#2) was performed following deployment of the  

stent, demonstrating appropriate positioning and wide patency of the stent,  

with excellent neck coverage over the aneurysm sac.  



Subsequently, an Echelon 10 microcatheter was advanced through the stent  

into the left anterior cerebral artery aneurysm sac and coil embolization of  

the aneurysm was performed. A total of 7 coils were attempted, and 4 coils  

were deployed. Control angiograms (#3-6) were performed intermittently  

throughout the embolization procedure to evaluate the results of the  

embolization. These control angiograms demonstrate appropriate positioning  

of the coil material within the aneurysm sac, with no herniation of coil  

material into the parent vessel. There is progressive filling of the  

aneurysm sac, with progressively decreasing contrast opacification of the  

aneurysm lumen.



The microcatheter was removed and a final control angiogram (#7) in the AP  

and lateral views was performed from the guiding catheter with filming over  

the intracranial circulation. This imaging sequence demonstrates appropriate  

positioning of the coil material within the aneurysm sac, with no herniation  

of coil material into the parent artery. The stent remains widely patent and  

appropriately positioned. There no significant residual filling of the  

aneurysm lumen. No thrombus formation or evidence of distal embolization.  

Capillary phase imaging demonstrates normal parenchymal opacification and  

arteriovenous transit time. The main intracranial venous structures fill  

appropriately.





IMPRESSION:



1. Left anterior cerebral artery aneurysm, measuring 3.6 x 3.7 x 4.1 mm,  

with a 2.9 mm neck, projecting anteriorly, with a 1.5 mm bleb arising from  

the aneurysm dome.

2. The above-described aneurysm was treated with stent-assisted coil  

embolization, resulting in aneurysm occlusion.



PLAN:



1. Aspirin 325 mg daily for life.

2. Plavix 75 mg daily for 6 months.

3. Followup Neurointerventional Surgery Clinic visit in one month.

4. DSA in 6 months.


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## s_harris14 (Jun 9, 2015)

Hi! I think I can help you with this one, but I need to look up a few of the codes. I've printed the report and will get back with you later today.

I can tell you that you are correct in coding 36224 for the internal carotid artery and dropping 36222 (common carotid) - you can only code the most selective branch.

36226 is used to code the vertebral artery, which I don't see performed in the report, but again I'm going to read it more carefully and then respond. 

61624 and 75894 are the correct codes for reporting intracranial embolization with S&I. 

75898 is the correct code for reporting the 7 follow-up angiograms; however, I recommend posting it on two lines: 
75898 x 1 
75898-59 x 6

Depending on the insurance, they will deny the additional 6 as exceeding the maximum number of units allowed per procedure. However, ZHealth Publishing notates in the Interventional Radiology Coding Reference that this rule is applicable only to peripheral embolizations and that for CNS embolization, there is not a maximum # of units for reporting follow-up angiograms. All carriers vary in how many they will pay you, but you can get payment for more than 1. It just takes time to appeal the denial. CMS denies every single claim, but pays for the additional 75898's every single time after a proper appeal is sent. 


Stephanie


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## s_harris14 (Jun 9, 2015)

Hello!

I read over the procedure report and I would code the procedure as:

36224
61624
75894
75898
75898-59 x 6

I didn't find where the physician selected and catheterized the vertebral artery (36226).

Hope this helps!
Stephanie


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