# CT guided embolization of a type II endoleak



## Jim Pawloski (Sep 19, 2012)

I need an opinion for codes of case below

Examination: CT guided embolization of a type II endoleak 

Clinical History: 79-year-old male status post aortic endovascular stent graft
 repair for a abdominal aortic aneurysm. Serial CAT scans demonstrates a type  
II endoleak. Two attempts were made to embolize the endoleak via the  
endovascular approach which was unsuccessful.


Access site: Left posterior flank.

Sedation: General anesthesia.

Contrast: 10 cc of Isovue.

Complications: None.

Technique:

The procedure, with the risk and benefits, were discussed with the patient.  
Informed and written consent were obtained and placed placed in the patient's  
chart.

The patient was brought to the CAT scan suite and placed on the gantry. The  
patient was administered general anesthesia by the anesthesiology team.  
Following endotracheal intubation, the patient was positioned in a right  
lateral recumbent position.

A radiopaque grid was placed over the left posterior flank. Contiguous 3 mm  
axial images were obtained from the proximal endovascular aortic stent to the  
iliac crest. This exam is limited due to no oral or intravenous contrast. The  
purpose of this limited CT scan was to localize an access site for CT guided  
embolization.

The access site was chosen from the transaxial CT images. The left posterior  
flank was prepped and draped in the normal sterile fashion. A small  
dermatotomy was made with an 11 blade scalpel. An 18-gauge 20 cm Chiba needle  
was advanced into the aneurysm sac utilizing CT fluoroscopy.

Once the needle was within the aneurysm sac, a small amount of contrast was  
injected during fluoroscopy demonstrating filling of the aneurysm sac with  
outflow through a lumbar artery. The amount of contrast used to opacify the  
aneurysm sac was approximately 3 cc.

At this time, 1 cc of n- Butyl cyanoacrylate (Tru-fill glue) was mixed with 2  
cc of Ethiodol. The 3cc of the mixture was injected through the 18-gauge  
needle under direct fluoroscopy. Following embolization of the aneurysm sac,  
the needle was removed. A sterile dressing was placed.

A limited CT scan was performed through the abdomen to evaluate embolization  
of the aneurysm sac.

The patient tolerated the procedure well and left the angiography suite and  
stable condition.

Findings:

Limited CT scan of the abdomen demonstrates the patient is status post aortic  
endovascular stent graft placement. Injection of contrast in the aneurysm sac  
demonstrates a patent type II endoleak with outflow through the lumbar artery.

Following embolization, there is increased density opacifying the aneurysm sac
 and outflow artery. There is no evidence of extravasated contrast or  
bleeding.

Impression:

1. Successful CT guided embolization of a type II endoleak with N-Butyl  
cyanoacrylate (Tru-Fill glue)

2. The patient is scheduled for a 4 weeks triple phase CTA to evaluate for  
endoleak and will follow-up in the interventional clinic for the results.

I think 36160, 76380, 37204, 75984.  Would you use a fluoro charge, since fluoroscopy was used in the CT scanner.  What do you think?

Thanks,
Jim Pawloski, CIRCC


----------



## dpeoples (Sep 19, 2012)

Jim Pawloski said:


> I need an opinion for codes of case below
> 
> Examination: CT guided embolization of a type II endoleak
> 
> ...



Jim,
I would consider the injection under fluoro to be part of the S & I portion of the embolization and would be part of 75894. Therefore, I would not charge an additional code for fluoro guidance. 

However, I would consider charging for CT guidance (77012) since the needle placement site was deteremined by CT images. 


I agree with the other codes.

HTH


----------



## Jim Pawloski (Sep 20, 2012)

dpeoples said:


> Jim,
> I would consider the injection under fluoro to be part of the S & I portion of the embolization and would be part of 75894. Therefore, I would not charge an additional code for fluoro guidance.
> 
> However, I would consider charging for CT guidance (77012) since the needle placement site was deteremined by CT images.
> ...



So you would replace the 76380 (limited CT) for 77012 - CT guidance?

Jim


----------



## dpeoples (Sep 20, 2012)

Jim Pawloski said:


> So you would replace the 76380 (limited CT) for 77012 - CT guidance?
> 
> Jim



Jim,
I would actually code for both. Although they were done in the same session, they are very clearly documented as being done for different reasons, at different times during the session.

My bundling program says to append modifier 59 to 76380. 

HTH


----------



## Jim Pawloski (Sep 20, 2012)

dpeoples said:


> Jim,
> I would actually code for both. Although they were done in the same session, they are very clearly documented as being done for different reasons, at different times during the session.
> 
> My bundling program says to append modifier 59 to 76380.
> ...



Great!  Thank you very much for your help.

Jim


----------

