Wiki Cath/Angio prior to Embo

[margaret fahy]

02/21/14
Can someone help me with this one?
In report below, I'm confused re the catheterization prior to Embo.
I'm thinking, as there was an MRA done on same day prior to the embo, I'd code for catheterization of the vessels..and not angiography.
So I have 76937 for vascular access and 36216...and no RS&I? I thought it was just the angiographies where the RS&I is included. Our Endcoder refers one to 75710 and 75962; in the examples of head/neck catheterizations in our CSI book, no RS&I is attached....i thought i remember there being rs&i codes with the catheterizations....

36216, 76937, 61624, 75894, 75898 X4? I didn't code for the superselective catheterizatios, as the embo procedure had started...i think i messed this up and now i have a headache...can you help me?

PROCEDURE: Embolization of Vein of Galen Aneurysmal Malformation.
HISTORY: 2-month-old infant with history of PAPVR, sinus venous
ASD, vein of Galen aneurysmal malformation with failure to thrive
and high output cardiac failure.

COMPARISON: Brain MRI/MRA performed on 2/13/2014.

VESSELS SELECTED:
Left vertebral artery.
Posterior choroidal pedicles.
COMPLICATIONS: None.
CONTRAST: 20 mL of Isovue given intra-arterially. Nonionic
contrast was utilized for the patient's safety.
ANESTHESIA: The patient was administered general endotracheal
anesthesia under the care and supervision of the attending
anesthesiologist.
TECHNIQUE:
The procedure, its risks, benefits, and alternatives were
discussed in detail with the patient. Risks include but are not
limited to: bleeding, infection, nerve injury, vessel injury,
limb loss, groin hematoma, pulmonary damage, pain, radiation
exposure, alopecia, renal toxicity, renal failure, and allergic
reaction to contrast, stroke, blindness, coma, paralysis, death,
and the need for additional treatments. All questions were
answered and no guarantees were provided.
After informed consent the patient was brought into the
angiography suite and placed supine on the angiographic table.
The CHOP Interventional Radiology service, Dr., obtained
access to the right femoral artery using ultrasound guidance and
placed a 45-cm 4F sheath. Using a 0.035 inch Glidewire, the
sheath was advanced to the distal cervical left vertebral artery
at C2/C3 junction. Multiple posterior choroidal pedicles
supplying the vein of Galen aneurysmal malformation were selected
using a Syncro10 microwire and UltraFlow catheter with roadmap
guidance and continuous fluoroscopy monitoring.
FINDINGS:

LEFT VERTEBRAL ARTERY INJECTION, HEAD VIEWS: There is a large
vein of Galen aneurysmal malformation with arterial supply from
multiple posterior choroidal pedicles.

An intervention was performed as follows.
INTERVENTION:
A right-sided posterior choroidal pedicle was selected using a
Syncro10 microwire and UltraFlow catheter with roadmap guidance
and continuous fluoroscopy monitoring. Superselective angiography
of this pedicle show only arteriovenous fistula and no normal
parenchyma. The pedicle was embolized using n-butyl cyanoacrylate
(NBCA). Postembolization angiography showed obliteration of the
embolized posterior choroidal pedicle with no contrast filling.
Using overlaying technique, the prior angiogram was used as
reference roadmap to minimize the use of intravenous contrast.
Three additional left-sided posterior choroidal pedicles were
selected and superselective angiography through the microcatheter
performed. Superselective angiography showed only arteriovenous
fistula and no normal parenchyma. Each pedicle was embolized with
NBCA. Final postembolization angiogram showed significant
decrease in flow to and filling of the vein of Galen aneurysmal
malformation.
At the completion of the procedure, the catheter and sheath were
removed by the CHOP IR service and hemostasis in the right groin
obtained by manual compression under right foot post oxygenation
monitoring.
No new neurological deficits or complications were encountered
during or immediately following the procedure.

IMPRESSION

Successful endovascular NBCA glue embolization multiple pedicles
feeding a vein of Galen aneurysmal malformation as described.

Dr. was present during the whole procedure and is
personally responsible for its interpretation.


Result History

 

[NBLEYL]

If the diagnostic angiography was done to evaluate if they could correct it with percutaneous approach, you CAN code for the angiography. I can't really tell with his dictation, I usually look for a statement like "after diagnostic study, decision to procede with...". The MRA does not preclude you from being able to bill the angiography because it is not a catheter based study. You may want to ask your physician about that.
As for the ultrasound guidance to access the vessel, I do not see enought documentation to bill 76937. At a minimun, he has to state 1 - the vessel was patent, 2 - permanent images were stored and 3 - realtime ultrasound guidance was used to visualize needle entry. I would not code that.
If the doctor clarifies that the angiography was necessary prior to doing the procedure (it appears that he did the study and then went on to the intervention, but I would ask for an addendum to clarify this) I would code 61624, 36226, 36228, 36228 (you can only bill for 3 additionals per side even though he did 3), 75984 and 75898 x 2.