# Transarterial Embolization. Help !!!:confused:



## jonyleo20 (Oct 5, 2012)

Hello I am new at Interventional Rad. I have a case where I feel confuse. When I first read it my impresion was since it was through the vertebral Artery i thought of 61626 but then i've got a sec opinion  

At first I have Coded it as follow:
61626
36217
75894,26
75898,26
75685,26

Then I asked a co-worker and he came out with a diferent set as follow:
61624
36217
36218,59 x 2
75898,26 x 2
75894,26
75685,26
75774,26,59 x 3

Here is the report and I am so sorry for the Caps. it was extracted from a program that won't allow me to change it  . Thanks for your time and assitance. 

Report:

 VESSELS INJECTED- 
 RIGHT VERTEBRAL ARTERY, 
 SUPERSELECTIVE RIGHT P3-PCA, PARIETAL-OCCIPITAL (PO) DIVISION 
 SUPERSELECTIVE RIGHT P4-PCA, PARIETAL-OCCIPITAL (TO) DIVISION 
 SUPERSELECTIVE RIGHT P4-PCA X 2 
 ABDOMINAL AORTA
 OPERATIONS/PROCEDURES- THE PROCEDURES, RISKS (INCLUDING STROKE, 
 DEATH, BLEEDING, COMA, DAMAGE TO BLOOD VESSELS, INFECTION, AND 
 ADVERSE REACTION TO MEDICATIONS), BENEFITS, AND ALTERNATIVES WERE 
 DISCUSSED WITH THE PATIENT AND HER FAMILY, IN WHICH ALL QUESTIONS 
 WERE ANSWERED AND INFORMED CONSENT WAS OBTAINED. THE PATIENT WAS 
 BROUGHT INTO THE NEURO-INTERVENTIONAL SUITE AND PLACED ON THE 
 FLUORO/DSA TABLE IN A SUPINE POSITION. A PROCEDURAL TIMEOUT WAS TAKEN 
 TO VERIFY THE CORRECT PATIENT AND INTERVENTION. BOTH GROINS WERE 
 PREPPED AND DRAPED IN THE USUAL STERILE FASHION. 
 THE RIGHT COMMON FEMORAL ARTERY WAS THEN ACCESSED VIA A MODIFICATION 
 OF THE SELDINGER TECHNIQUE USING SINGLE WALL PUNCTURE TECHNIQUE WITH 
 AN 18G SINGLEWALL NEEDLE. PULSATILE ARTERIALIZED FLOW WAS OBSERVED, 
 IN WHICH A GUIDEWIRE WAS THEN INSERTED AND POSITIONED INTO THE AORTA 
 UNDER FLUOROSCOPIC GUIDANCE. A #7 FRENCH 23 CENTIMETER SHEATH WAS 
 SUBSEQUENTLY COAXIALLY PLACED OVER A GUIDEWIRE THROUGH THE RIGHT CFA 
 ARTERIOTOMY AND CONNECTED TO A PRESSURIZED CONTINUOUS HEPARINIZED 
 NORMAL INFUSION. 
 A #6-FRENCH 070 NEURON GUIDING CATHETER/# 5-FRENCH NEURON SELECT 
 BERENSTEIN COMBINATION WAS ADVANCED OVER A 0.035" TERUMO GLIDEWIRE 
 INTO THE ASCENDING AORTA, AND THEN MANIPULATED SERIALLY INTO THE 
 RIGHT SUBCLAVIAN AND EVENTUALLY DISTAL RIGHT VERTEBRAL ARTERY UNDER 
 DSA SUBTRACTED FLUOROSCOPIC GUIDANCE FOR SELECTIVE CATHETER DSA AS 
 FOLLOWS- 
 THE RIGHT VERTEBRAL ARTERY WAS THEN SELECTIVELY CATHETERIZED IN WHICH 
 BIPLANE CEREBRAL ANGIOGRAPHY WAS PERFORMED WITH MULTIPLANAR VIEWS 
 OBTAINED. 
 FINDINGS ON SELECTIVE CATHETER DSA- 
 CEREBRAL ANGIOGRAPHY FROM RIGHT VERTEBRAL ARTERY CEREBRAL ANGIOGRAM 
 (MULTIPLANAR VIEWS)- THE CERVICAL PORTIONS OF THE RIGHT VERTEBRAL 
 ARTERY ARE OF NORMAL COURSE AND CALIBER. THERE IS NO REFLUX OF 
 CONTRAST INTO THE CONTRALATERAL LEFT VERTEBRAL ARTERY. THE BASILAR 
 ARTERY IS MODERATELY ECTATIC BUT NORMAL CALIBER. NORMAL RIGHT PICA 
 DISTRIBUTION. BILATERAL SUPERIOR CEREBELLAR ARTERIES ARE OF NORMAL 
 COURSE AND CALIBER. AGAIN NOTED IS A MEDIUM-SIZE BRAIN AVM SITUATED 
 WITHIN THE RIGHT OCCIPITAL LOBE. THE DISTAL PCA SUPPLY APPEARS TO 
 ARISE FROM A MAJOR (PRIMARY) TEMPORAL OCCIPITAL BRANCH WHICH GIVES 
 OFF TO PRINCIPAL FEEDING SUBPEDICLES (SUPERIOR AND INFERIOR).  THE 
 DISTAL TERRITORY AND CORRESPONDING NIDAL COMPARTMENT FROM THE 
 PREVIOUSLY DESCRIBED MINOR TEMPORAL-OCCIPITAL BRANCH TO THE AVM IS 
 OCCLUDED. THE AVM SHOWS EVIDENCE OF CONGESTIVE VENOUS DRAINAGE AND 
 VENOUS ANEURYSM FORMATION. THERE ARE AT LEAST TWO INTRA-NIDAL 
 ANEURYSMS AS NOTED EARLIER. THE AVM NIDUS MEASURES APPROXIMATELY 2 
 CENTIMETERS IN GREATEST DIMENSION.  
 NEURO-ENDOVASCULAR SURGICAL PROCEDURES- 
 1. SUPERSELECTIVE ENDOVASCULAR SURGICAL EXPLORATION OF RIGHT P3-PCA 
 AND TWO SEPARATE RIGHT P4-PCA FEEDING BRANCHES OF BRAIN AVM 
 2. ULTRA-SUPERSELECTIVE MICROCATHETERIZATION AND TRANSARTERIAL 
 EMBOLIZATION USING LIQUID NON-ADHESIVE NIDAL EMBOLIZATION WITH 
 ETHYLENE VINYL ALCOHOL COPOLYMER (ONYX) OF SUPERIOR COMPARTMENT OF 
 BAVM VIA TERMINAL FEEDING PEDICLE ARISING FROM P4-PCA 
 PARIETAL-OCCIPITAL DIVISION.
 3. ULTRA-SUPERSELECTIVE MICROCATHETERIZATION AND TRANSARTERIAL 
 EMBOLIZATION USING LIQUID NON-ADHESIVE NIDAL EMBOLIZATION WITH 
 ETHYLENE VINYL ALCOHOL COPOLYMER (ONYX) OF INFERIOR COMPARTMENT OF 
 BAVM VIA TERMINAL FEEDING PEDICLE ARISING FROM P4-PCA 
 PARIETAL-OCCIPITAL DIVISION.
 ENDOVASCULAR SURGICAL EXPLORATION WAS PERFORMED BY SUPERSELECTIVE 
 MICROCATHETER TECHNIQUE TO DETERMINE THE FAVORABILITY OF THE LESION 
 FOR ULTRA SUPERSELECTIVE TRANS ARTERIAL EMBOLIZATION. A 1.5-FRENCH 
 MARATHON MICROCATHETER WITH A .008" MIRAGE MICROGUIDEWIRE WAS 
 NAVIGATED WITHIN THE INTRACRANIAL RIGHT POSTERIOR CIRCULATION UNDER 
 FLUOROSCOPIC GUIDANCE AND ROAD MAPPING. THE MICROCATHETER WAS FIRST 
 PLACED IN THE RIGHT P3-PCA SEGMENT. 
 SUPERSELECTIVE P3-PCA DSA- BIPLANE DSA SHOWS THE MICROCATHETER TO BE 
 IN NON-WEDGE POSITION OF THE DISTAL MAIN PCA TRUNK IN WHICH 
 DOWNSTREAM THERE IS A TORTUOUS DISTAL P4-PCA BRANCH THAT GIVES RISE 
 TO THE PRIMARY SUPPLY TO THE AVM ARISING FROM THE PARIETAL-OCCIPITAL 
 DIVISION. THERE APPEAR TO BE FISTULOUS COMPONENTS TO THE AVM AS WELL 
 AS COMPACT NIDUS. ULTRASUPERSELECTIVE MICROCATHETERIZATION WAS THEN 
 PERFORMED WITH DSA ROADMAPPING AND CONTINUOUS FLUOROSCOPY OF THE 
 UPPER TERMINAL P4-PCA FEEDING PEDICLE.
 RIGHT P4-PCA FEEDING PEDICLE #1 (USS-DSA#2)- BIPLANE DSA FROM P4 
 TEMPORAL-OCCIPITAL TERMINAL SUPERIOR DIVISION INJECTIONS SHOW THE 
 CATHETER TO BE UNDER WEDGE CONDITIONS. THIS SHOWED DELAYED 
 ARTERIOVENOUS SHUNTING THROUGH A MIXED FISTULOUS AND PLEXIFORM NIDAL 
 SUPEROMEDIAL COMPARTMENT OF THE AVM. THIS BRANCH PROVIDES A SMALL 
 PORTION OF SUPPLY TO THE AVM. A NIDAL ANEURYSM IS AGAIN SEEN WITHIN 
 THIS COMPARTMENT. 
 ENDOVASCULAR SURGICAL OBLITERATION AVM COMPARTMENT #1- UNDER 
 CONTINUOUS FLUOROSCOPIC GUIDANCE AND BLANK SUBTRACTED FLUOROSCOPY, A 
 CONTINUOUS COLUMN OF ONYX 18 WAS VERY SLOWLY, AND INTERMITTENTLY 
 INJECTED INTO THE AVM NIDUS IN WHICH SIGNIFICANT RETROGRADE REFLUX 
 INTO THE PRIMARY FEEDING PEDICLE OCCURRED. THIS PERMITTED 
 SUBSEQUENTLY EXCELLENT FLOW CONTROLLED DISTAL EMBOLIZATION OF THE 
 TARGETED NIDUS. THE EMBOLIC AGENT SLOWLY PENETRATED WELL INTO THE 
 TARGETED COMPARTMENT OF THE AVM NIDUS RESULTING IN EXCELLENT 
 OBLITERATION OF A SIGNIFICANT PORTION OF THE INFERIOR COMPARTMENT THE 
 AVM. NO NONTARGET DELIVERY OF THE EMBOLIC AGENT WAS NOTED. 
 CONTROL DSA FROM SELECTIVE RIGHT VERTEBRAL INJECTION- BIPLANE DSA 
 SHOWS APPROXIMATELY 60% OVERALL NIDAL VOLUME REDUCTION OF THE AVM 
 WITH PRESERVATION OF THE PRINCIPAL DRAINING VEINS. THERE HAS BEEN 
 SIGNIFICANT REDUCTION IN OVERALL AV SHUNTING. THE DISTAL PCA 
 TERRITORIES WITHIN TEMPORAL AND PARIETAL LOBES APPEAR NORMAL, WITHOUT 
 EVIDENCE OF EMBOLIC OCCLUSION.
 ENDOVASCULAR SURGICAL EXPLORATION WAS PERFORMED BY SUPERSELECTIVE 
 MICROCATHETER TECHNIQUE TO DETERMINE THE FAVORABILITY OF THE LESION 
 FOR ULTRA SUPERSELECTIVE TRANS ARTERIAL EMBOLIZATION. A 1.5-FRENCH 
 MARATHON MICROCATHETER WITH A .008" MIRAGE MICROGUIDEWIRE WAS 
 NAVIGATED WITHIN THE INTRACRANIAL RIGHT POSTERIOR CIRCULATION UNDER 
 FLUOROSCOPIC GUIDANCE AND ROAD MAPPING. THE MICROCATHETER WAS THEN 
 PLACED IN THE RIGHT P3-PCA SEGMENT. ULTRASUPERSELECTIVE 
 MICROCATHETERIZATION WAS THEN PERFORMED WITH DSA ROADMAPPING AND 
 CONTINUOUS FLUOROSCOPY OF THE LOWER, DOMINANT TERMINAL P4-PCA FEEDING 
 PEDICLE.
 RIGHT P4-PCA FEEDING PEDICLE #2 (USS-DSA#4)- BIPLANE DSA FROM P4 
 PARIETAL-OCCIPITAL TERMINAL DIVISION INJECTIONS SHOW THE CATHETER TO 
 BE UNDER NEAR-WEDGE CONDITIONS. THIS SHOWED ARTERIOVENOUS SHUNTING 
 THROUGH A MIXED FISTULOUS AND PLEXIFORM NIDAL INFEROMEDIAL 
 COMPARTMENT OF THE AVM. NORMAL CORTICAL BRANCHES WERE NOT VISUALIZED 
 PROXIMAL TO THE SITE OF AV SHUNTING. NIDAL ANEURYSMS ARE AGAIN SEEN 
 WITHIN THIS COMPARTMENT. 
 ENDOVASCULAR SURGICAL OBLITERATION AVM COMPARTMENT #2- UNDER 
 CONTINUOUS FLUOROSCOPIC GUIDANCE AND BLANK SUBTRACTED FLUOROSCOPY, A 
 CONTINUOUS COLUMN OF ONYX 16 WAS VERY SLOWLY, AND INTERMITTENTLY 
 INJECTED INTO THE AVM NIDUS IN WHICH SIGNIFICANT RETROGRADE REFLUX 
 INTO THE PRIMARY FEEDING PEDICLE OCCURRED. THIS PERMITTED 
 SUBSEQUENTLY EXCELLENT FLOW CONTROLLED DISTAL EMBOLIZATION OF THE 
 TARGETED NIDUS. THE EMBOLIC AGENT SLOWLY PENETRATED WELL INTO THE 
 TARGETED COMPARTMENT OF THE AVM NIDUS RESULTING IN EXCELLENT 
 OBLITERATION OF A SIGNIFICANT PORTION OF THE INFERIOR COMPARTMENT THE 
 AVM. NO NONTARGET DELIVERY OF THE EMBOLIC AGENT WAS NOTED. 
 FINAL CONTROL DSA FROM SELECTIVE RIGHT VERTEBRAL INJECTION- BIPLANE 
 DSA SHOWS GREATER THAN 95% OVERALL NIDAL VOLUME REDUCTION OF THE AVM 
 WITH PRESERVATION OF THE PRINCIPAL DRAINING VEINS. THERE HAS BEEN 
 DRAMATIC REDUCTION IN OVERALL AV SHUNTING. THE DISTAL PCA TERRITORIES 
 WITHIN TEMPORAL AND PARIETAL LOBES APPEAR NORMAL, WITHOUT EVIDENCE OF 
 EMBOLIC OCCLUSION. THERE IS EN PASSANT SUPPLY FROM A 
 TEMPORAL-OCCIPITAL BRANCH OF THE RIGHT PCA, WHICH IS NOT ACCESSIBLE 
 TO SUPERSELECTIVE MICROCATHETERIZATION.  
 AFTER COMPLETION OF ENDOVASCULAR SURGERY, ALL CATHETERS WERE REMOVED. 
 AORTO-ILIAC BIFURCATION DSA WAS INITIALLY PERFORMED AND SUBSEQUENTLY, 
 THE 7 FR ARTERIAL SHEATH WAS SUTURED INTO THE ADJOINING SKIN FOR USE 
 AS A CONTINUOUS ARTERIAL PRESSURE LINE. 
 AORTO-BI-ILIAC DSA- FLUSH INJECTION IN AP PROJECTION SHOWS ABNORMAL 
 CALIBER OF THE RIGHT COMMON ILIAC,'
 MAY BE DUE TO VASOSPASM FORM SHEATH.
 BILATERAL ILIO FEMORAL ARTERIAL TREE, WITHOUT EVIDENCE OF STENOSIS OR 
 OCCLUSION THERE IS NORMAL TRANSIT TIME THERE IS NO EVIDENCE OF 
 STENOSIS OR DISSECTION WERE BLEEDING FROM THE ARTERIOTOMY SITE. PULL 
 BACK INTO THE LEFT COMMON ILIAC ARTERY, DIAGNOSTIC DSA VIA HAND FLUSH 
 INJECTION SHOWS A COMPLETELY NORMAL LEFT ILIOFEMORAL ARTERIAL TREE 
 WITHOUT EVIDENCE OF STENOSIS, THROMBUS FORMATION OR DISSECTION. THE 
 ARTERIOTOMY SITE IS ABOVE THE COMMON FEMORAL ARTERY BIFURCATION AND 
 BELOW THE INGUINAL LIGAMENT. AN 8-FRENCH ANGIO-SEAL ARTERIOTOMY 
 CLOSURE KIT WAS USED FOR PERCUTANEOUS CLOSURE OF THE ARTERIOTOMY. 
 IMMEDIATE HEMOSTASIS WAS ATTAINED. 
 SUMMARY/IMPRESSION-


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## Jim Pawloski (Oct 15, 2012)

jonyleo20 said:


> Hello I am new at Interventional Rad. I have a case where I feel confuse. When I first read it my impresion was since it was through the vertebral Artery i thought of 61626 but then i've got a sec opinion
> 
> At first I have Coded it as follow:
> 61626
> ...



I agree with your co-workers with the codes.  First, the code 61626 is for non-CNS embolization.  Also, three different branches of the vertebral artery was selected, and imaged, so that is where 36217 and two 36218 charges are billed, then one 75685 for vertebral and 75774 used for the other two branches.  61624 and 75894 for the embolization and 75898 x3 for post embolization imaging.
HTH,
Jim Pawloski, CIRCC


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## jonyleo20 (Nov 28, 2012)

Jim Pawloski said:


> I agree with your co-workers with the codes.  First, the code 61626 is for non-CNS embolization.  Also, three different branches of the vertebral artery was selected, and imaged, so that is where 36217 and two 36218 charges are billed, then one 75685 for vertebral and 75774 used for the other two branches.  61624 and 75894 for the embolization and 75898 x3 for post embolization imaging.
> HTH,
> Jim Pawloski, CIRCC





Jim, Thank you very much for your advise. I really appreciate your time and assistance .


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