# Embolization - 80-year-old male with history of cholangiocarcinoma



## prabha (Aug 21, 2009)

37204
36247
36247-59
75894-26
75898-26
75726-26
75726-2659
75774-26

Pls confirm my codes for the below procedure

   CLINICAL HISTORY:       
       80-year-old male with history of cholangiocarcinoma
       liver status post right and left biliary drainage catheters.
       Biliary tube change performed yesterday demonstrates communication
       of the left biliary drainage transhepatic tract with the segment
       two branch of the left hepatic artery resulting in hemobilia.  The
       patient is now referred for embolization of the segment II branch
       of the left hepatic artery.

       PROCEDURE:      

       The right groin was prepped and draped in sterile fashion. A 21
       gauge single wall puncture of the right common femoral artery was
       performed using a Seldinger technique utilizing real time
       ultrasound guidance. A guide wire was passed in retrograde
       fashion. A 5 French vascular sheath was advanced.

       A 4-French Sos selective one catheter was used to select the
       superior mesenteric artery.  Contrast was injected and digital
       subtraction angiography was performed.  Using a guidewire and
       catheter combination, the origin of the inferior
       pancreaticoduodenal arcade was selected.  The catheter was
       advanced and digital subtraction angiography of the inferior
       pancreaticoduodenal arcade (iPDA) was performed.

       A glide wire and glide catheter were manipulated into the inferior
       pancreaticoduodenal arcade (iPDA) and into the gastroduodenal
       artery.  The catheter was advanced into the junction of the GDA
       and common hepatic artery.  Contrast was injected and digital
       subtraction angiography was performed.

       Multiple different guidewire and catheter combinations were
       attempted to select the left hepatic artery.  Eventually, a
       5-French sheath was advanced to the iPDA and a glide wire was used
       to pass a 4-French glide Simmons catheter (tip cut off) to the
       level of the proximal GDA.  A renegade microcatheter and double
       angled Glidewire was used to select the segment two branch of the
       left hepatic artery.  Transcatheter embolization was performed
       using multiple Nestor and platinum microcoils.  A small amount of
       Gelfoam slurry was also injected.  There is significant slowing of
       the flow in the segment two branch of the left hepatic artery.  A
       coil also was placed in the segment two branch of the left hepatic
       artery.

       Post embolization angiography was performed.

       Following embolization, the right groin sheath was removed and
       hemostasis was achieved with direct mild compression over the
       puncture site. There were no immediate complications.


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## Jim Pawloski (Aug 23, 2009)

prabha said:


> 37204
> 36247
> 36247-59
> 75894-26
> ...





I will agree with most of your codes, however, I feel that one branch was selected because of the path of the catheter through the SMA to the GDA to Lt Hepatic.  Since the Celiac is not mention, I wonder if it was occluded.  So I would go 36247 for selection of the Lt Hepatic from the SMA origion.  With the SMA imaged, that would be the visceral charge 75726.  The iPDA would be 75774-59 would be the next imaging performed. GDA-Common Hepatic imaging could be 75774-59 since it was selected from the SMA branch, not from the Celiac(?).  Then the embolization charge 37204-59 would be next with the S&I 75894-59.  Post embolization charge would be 75898.  I also wonder about the modifier 26, is the institution where this was performed billing their part of the S&I?

I hope this helps you out,
Jim


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