Wiki Transcath Emoblization Coding Help Needed

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cswift

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Help Please?? Could anyone please offer any assistance with my coding on this Transcatheter Embolization? I am coming up with 37204-Rt, 75894-Rt, 36245-59, 36247-Rt, 75774-Rt, 75898, 75898-59.

Thanks!


FINAL
HISTORY: A 93-year-old black female who is well known to this
physician from previous treatments of multifocal hepatocellular
carcinoma. Patient has undergone prior transarterial chemoembolization
surgeries over the past several years. She is referred again now for
re-evaluation secondary to possible new tumor mass on outside CT as
well as elevated alpha-fetoprotein levels.

Informed consent was obtained with the patient and her family with
delineation of risks, benefits, expectations and alternatives. Patient
agreed to undergo diagnostic arteriography and possible embolization.

Intravenous conscious sedation was utilized for today's surgery with
continuous nursing and physician monitoring for approximately 90
minutes.

After informed consent, patient's right groin was sterilely prepped
and draped. Arterial access was obtained and using standard Seldinger
technique, a 6-French vascular sheath was placed in the right common
femoral artery and established to a continuous heparinized saline
flush. Systemic heparin was also administered. Patient has previously
undergone diagnostic abdominal aortography for evaluation of the
mesenteric vasculature and did not undergo additional aortography at
this time. The main hepatic artery is noted to arise off the proximal
superior mesenteric artery and this arterial trunk was going to be the
targeted vessel.

I initially catheterized the celiac trunk. Controlled angiography did
not demonstrate any neoplastic tumor neovascularity. The catheter was
then withdrawn and positioned in the proximal SMA. Controlled
arteriograms were then performed in several projections which did
demonstrate right hepatic artery flow with an approximate 2.5-cm tumor
blush in the right lobe towards the dome. The 5-French Cobra catheter
was then established to a continuous heparinized saline flush as well.
A microcatheter and guidewire system were employed for superselective
catheterization of the proper hepatic artery. The acute origin
posteriorly off the SMA was difficult to cannulate but I was able to
finally get a 0.014 Agility wire out distally within this vessel. The
Renegade microcatheter was then also advanced out into the hepatic
hilum. Controlled microcatheter angiography was then performed
allowing good visualization of the tumor neovascularity. The
microcatheter was advanced as far distally as possible and controlled
embolization was subsequently performed. Patient was given systemic
steroids and polyvinyl alcohol-impregnated particulate material was
embolized into the distal hepatic artery branches until complete
hemostasis was obtained. There was no adjuvant chemotherapy
administered transarterially at this setting. Once complete hemostasis
was obtained with bland particulate embolization, the parent vessel
was occluded with bioactive coils. This is performed successfully
without difficulty and the microcatheter system was completely
removed. Completion angiography through the 5-French guiding catheter
in the superior mesenteric artery trunk demonstrated good technical
results and the procedure was terminated. The diagnostic catheter and
right femoral sheath were removed, hemostasis was obtained and patient
was admitted for overnight observation and pain management.

IMPRESSION:
1. Selective hepatic angiography does demonstrate tumor neovascularity
with a 2.5-cm blush noted in the right lobe of the liver towards the
dome.

2. Patient underwent targeted endovascular embolization with
completion angiography demonstrating good technical results.
 
cswift said:
Help Please?? Could anyone please offer any assistance with my coding on this Transcatheter Embolization? I am coming up with 37204-Rt, 75894-Rt, 36245-59, 36247-Rt, 75774-Rt, 75898, 75898-59.

Thanks!


FINAL
HISTORY: A 93-year-old black female who is well known to this
physician from previous treatments of multifocal hepatocellular
carcinoma. Patient has undergone prior transarterial chemoembolization
surgeries over the past several years. She is referred again now for
re-evaluation secondary to possible new tumor mass on outside CT as
well as elevated alpha-fetoprotein levels.

Informed consent was obtained with the patient and her family with
delineation of risks, benefits, expectations and alternatives. Patient
agreed to undergo diagnostic arteriography and possible embolization.

Intravenous conscious sedation was utilized for today's surgery with
continuous nursing and physician monitoring for approximately 90
minutes.

After informed consent, patient's right groin was sterilely prepped
and draped. Arterial access was obtained and using standard Seldinger
technique, a 6-French vascular sheath was placed in the right common
femoral artery and established to a continuous heparinized saline
flush. Systemic heparin was also administered. Patient has previously
undergone diagnostic abdominal aortography for evaluation of the
mesenteric vasculature and did not undergo additional aortography at
this time. The main hepatic artery is noted to arise off the proximal
superior mesenteric artery and this arterial trunk was going to be the
targeted vessel.

I initially catheterized the celiac trunk. Controlled angiography did
not demonstrate any neoplastic tumor neovascularity. The catheter was
then withdrawn and positioned in the proximal SMA. Controlled
arteriograms were then performed in several projections which did
demonstrate right hepatic artery flow with an approximate 2.5-cm tumor
blush in the right lobe towards the dome. The 5-French Cobra catheter
was then established to a continuous heparinized saline flush as well.
A microcatheter and guidewire system were employed for superselective
catheterization of the proper hepatic artery. The acute origin
posteriorly off the SMA was difficult to cannulate but I was able to
finally get a 0.014 Agility wire out distally within this vessel. The
Renegade microcatheter was then also advanced out into the hepatic
hilum. Controlled microcatheter angiography was then performed
allowing good visualization of the tumor neovascularity. The
microcatheter was advanced as far distally as possible and controlled
embolization was subsequently performed. Patient was given systemic
steroids and polyvinyl alcohol-impregnated particulate material was
embolized into the distal hepatic artery branches until complete
hemostasis was obtained. There was no adjuvant chemotherapy
administered transarterially at this setting. Once complete hemostasis
was obtained with bland particulate embolization, the parent vessel
was occluded with bioactive coils. This is performed successfully
without difficulty and the microcatheter system was completely
removed. Completion angiography through the 5-French guiding catheter
in the superior mesenteric artery trunk demonstrated good technical
results and the procedure was terminated. The diagnostic catheter and
right femoral sheath were removed, hemostasis was obtained and patient
was admitted for overnight observation and pain management.

IMPRESSION:
1. Selective hepatic angiography does demonstrate tumor neovascularity
with a 2.5-cm blush noted in the right lobe of the liver towards the
dome.

2. Patient underwent targeted endovascular embolization with
completion angiography demonstrating good technical results.
Click to expand...

I would remove the -RT modifier, since the SMA is a single branch, and remove one of the 75898, since you can only charge it once per embolization (exception is in the brain for aneurysm coilings). Otherwise, your good!
HTH,
Jim Pawloski, CIRCC
 
I would change 36247 to 36246, and I'd add 75726 x 2. While I think that he probably went to a 3rd order (right hepatic) artery, he does not say that. What he says is "The main hepatic artery is noted to arise off the proximal superior mesenteric artery and this arterial trunk was going to be the targeted vessel. " In that case, the main hepatic is 2nd order. In the description of his procedure he describes "A microcatheter and guidewire system were employed for superselective catheterization of the proper hepatic artery. The acute origin
posteriorly off the SMA was difficult to cannulate but I was able to finally get a 0.014 Agility wire out distally within this vessel. The Renegade microcatheter was then also advanced out into the hepatic hilum." He never actually says that he went beyond the proper hepatic that arises off the SMA (2nd order). He does say "The microcatheter was advanced as far distally as possible and controlled embolization was subsequently performed. Patient was given systemic steroids and polyvinyl alcohol-impregnated particulate material was
embolized into the distal hepatic artery branches.." - did he actually go into those branches to embolize them, or sit within the proper hepatic and embolize the opening of these branches (shut the doors on them in effect)? If he actually went into those branches, you can code catheterization for each one. I would ask the doctor where exactly did he catheterize?

You have 75774 which is additional selective angiography beyond the basic, but you don't have a basic angiogram coded, so 75726 for the celiac and 75726 for the SMA.

Donna J Richmond
 
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