# Mesenteric arteriogram - Can we code the above set of codes



## prabha

36245
75726-26


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
       observation.

       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
       attempted tomorrow.


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## Jim Pawloski

prabha said:


> 36245
> 75726-26
> 
> 
> 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
> observation.
> 
> 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
> attempted tomorrow.



You need to bill for the bilateral catheter choleangiogram and biliary tube exchanges.


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