Sample IVR or interventional radiology chart

Interventional radiology is not understood until we are able code the live charts. To learn radiology with coded sample charts I have already shared with my previous blog post. But, now we have to learn about he live coding of Percutaneous coding of radiology.

EXAM: INJ MRI Gad
Left shoulder arthrogram injection
History: Rotator cuff or labral tear
Procedure note: Following discussion of the risks and benefits of the procedure, consent was obtained. The left shoulder was sterilely prepped and draped in the usual fashion. Local lidocaine was administered. Using fluoroscopic guidance, a 25-gauge hypodermic needle was placed into the left shoulder joint using the rotator interval approach. Approximately 10cc of dilute gadolinium and radiopaque contrast was injected intra-articularly under fluoroscopic monitoring. The patient tolerated the procedure well and there were no immediate complications.



Impression: Status post successful intra-articular contrast injection for MRI.

Finalized
CPT: 23350, 77002-26


CEREBRAL ARTERIOGRAM:

INDICATION: Follow-up aneurysm coiling.
TECHNIQUE: Informed consent was obtained from the patient's husband.

Full explanation of the risks and benefits of the procedure were
discussed.
The patient was taken to the angiography suite, where her right groin
was prepped and draped in standard sterile fashion. The right common
femoral artery was punctured
using a micropuncture kit and a 5 French
sheath was placed. A 5 French Davis A1 catheter was selectively
placed into the left internal carotid artery and arteriography was
performed
here evaluating the head. Following completion of the
procedure, the sheath and catheters were removed and hemostasis was
achieved with manual compression. The patient tolerated the procedure
well, without evidence of immediate complication.

FINDINGS:
A single endovascular coil is again seen within the previously treated
anterior communicating artery aneurysm. There some minimal residual
filling of the aneurysm lumen, but the appearance is improved compared
to the prior arteriogram from yesterday, with evidence of progressive
thrombosis of the aneurysm lumen. No thromboembolic complications are
seen. No intraluminal clot is present.
These findings were discussed with Dr. Parker of neurosurgery.

IMPRESSION:
1. Progressive thrombosis of an endovascularly treated anterior
communicating artery aneurysm compared to the previous angiogram from
the previous day as above.
CPT: 36224-LT



ULTRASOUND-GUIDED RIGHT INTERNAL JUGULAR CENTRAL LINE PLACEMENT:

INDICATION/DIAGNOSIS: Pancreatitis

CONTRAST: 0 mL contrast
CONSENT: The procedure, risks, indications and alternatives were
explained. All questions were answered and informed consent was
obtained, signed and witnessed from the patient.

SEDATION: None.
TECHNIQUE:
The procedure was performed using maximal sterile barrier technique
including cap, mask, sterile gown, sterile glove, large sterile sheet,
hand hygiene, and 2% chlorhexidine scrub for cutaneous antisepsis.
The right neck was prepped and draped in the usual sterile fashion.

Ultrasound evaluation of the right internal jugular vein demonstrated
patency and compressibility without clot. An ultrasound image was
obtained and placed in the patient's medical record. Local anesthesia
was obtained with 1% lidocaine. The right internal jugular vein was
accessed under direct ultrasound visualization with a micropuncture
needle. A guidewire was advanced centrally. The tract was dilated.

A 7 French triple lumen central venous catheter was placed with the
tip at the right atrial/superior vena caval junction. The catheter
was flushed, sewn in place and is ready for immediate use. The
patient tolerated the entire procedure well.

FINDINGS:
Spot film was obtained documenting a smooth course with the tip at the
right atrial/superior vena caval junction. No catheter kinking. No
definite evidence for pneumothorax.

FLUOROSCOPY TIME: 0.1 of fluoroscopy time was used.
ESTIMATED BLOOD LOSS: Less than 10 mL
SPECIMENS: None
COMPLICATIONS: None

IMPRESSION:
1. Successful placement of a right internal jugular triple lumen
central line.
ICD: V58.81


LUMBAR PUNCTURE, DIAGNOSTIC:
PREPROCEDURE INDICATION/DIAGNOSIS: Headache.

TECHNIQUE: The procedure, risks, indications and alternatives were
explained to the patient. Informed consent was obtained.

The back was prepped and draped in the usual sterile fashion. Local
anesthesia was obtained with 1% lidocaine. Under direct fluoroscopic
visualization
a 22-gauge needle was advanced via a left approach at
L5. The needle was easily advanced into the thecal sac using this
approach. Opening pressure was obtained measuring 35 cm water.

The needle was removed. Patient tolerated the entire procedure well
with no immediate complication.

FLUOROSCOPY TIME: 0.1 minutes of fluoroscopy time was used.
ESTIMATED BLOOD LOSS: None.
SPECIMEN: 20 mL clear CSF sent to the laboratory for analysis.
IMPRESSION:
Technically successful fluoroscopically-guided lumbar puncture
.

Elevated opening pressure measuring 35 cm water.
CPT: 62270, 77003-26


STEREOTACTIC-GUIDED NEEDLE-WIRE LOCALIZATION OF BIOPSY MARKER, RIGHT:
BREAST
 INDICATION: Excision of the area of a biopsied benign phyllodes tumor
right breast 7:00 N4 position in this 24-year-old. 100% of the lesion
was removed at time of vacuum-assisted biopsy on 8/29/2013. A
ribbon-shaped marker was left at the biopsy site.

FINDINGS:
TECHNIQUE:
The risks, benefits and alternatives to the procedure were discussed
with the patient , who understood the above and signed the consent.

Site 1: Right breast 7:00 N4
The technologist and I evaluated the area of previous biopsy with
ultrasound. The marker can no longer be visualized after this many
months, and there is no recurrent tumor. Therefore, we proceeded to
stereotactic localization.
Stereotactic localization views were performed. A time out was
conducted to verify that the correct procedure was being performed on
the correct patient. A sterile surgical tray was used.
Following sterile skin prep and administration of local anesthesia, a
Kopans needle-wire localization device was advanced through the area
of concern and hook wire deployed. Stereotatic images were obtained
to document appropriate positioning of the localization wire.
Post-localization digital mammogram demonstrates the wire adjacent to
the marker, but the tip is several centimeters medial to the desired
location. This due to accordion effect when the breast is released
compression.
We returned to ultrasound, and using measurements from the nipple, an
"X" was placed on the skin over the area for the surgeon to target.

IMPRESSION:
Needle-wire localization of breast lesion.

The wire was secured to the patient's skin, and she proceeded to
surgery. I discussed this localization with her surgeon Dr. Clark by
telephone at noon on 4/29/2014.
CPT: 19283-RT



EXAM: CT-GUIDED LEFT SHOULDER ASPIRATION, ARTHROGRAM AND LOCAL ANESTHETIC INJECTION

INDICATION: I was requested to evaluate this patient for left worse than right shoulder pain. Patient has a history of a hockey injury. Symptoms are worse with activity.
PAST MEDICAL

HISTORY: ALLERGIES: PENICILLIN.

Patient denies any bleeding diathesis or chronic medical condition.

On examination there is no erythema or deformity. He has a normal range of motion. I determined that the patient is a candidate for the procedure.

PREPROCEDURE EVALUATION: The patient was screened by telephone prior to the date of the procedure and prior to the procedure for contraindications and none were identified. The procedure was explained to the patient including the risks of bleeding, infection, exacerbation of symptoms, nerve injury, systemic effects of steroids, and headache and the patient agreed to undergo the procedure. Preprocedure Visual Pain Analog Score was documented.

TECHNIQUE: A sterile tray and 25-gauge spinal needle were used. Local anesthesia was achieved in the skin and subcutaneous tissues with a 25-gauge needle with Xylocaine 1% buffered with bicarbonate. Under direct CT fluoroscopic guidance, the shoulder joint was entered. No fluid could be aspirated. An arthrogram was obtained with 8 mL of dilute saline, gadolinium, Omnipaque 180 and 1% Xylocaine in the usual concentration. There was no pain during injection. The arthrogram was normal. At the conclusion of the procedure, a dressing was placed.

IMPRESSION/POST-PROCEDURE EVALUATION: Successful aspiration and arthrogram. No effusion was present and the arthrogram was normal. No complications encountered. The patient was advised concerning expected outcomes, warning signs, and limitations of activity and a pain journal was given to the patient. VPAS level prior to the procedure was 0. Pain level post procedure was 0. The patient's physical exam findings were stable at discharge. The patient was discharged after meeting discharge criteria. Also, post-discharge instructions were given to the patient.
CPT: 23350, 77012-26


EXAM: CT-GUIDED LEFT HIP PRE-MRI INJECTION

PROCEDURE: Informed consent was obtained from the patient. After isolating the course of the femoral neurovascular bundle, the skin overlying the anterior aspect of the left hip was prepared and draped utilizing sterile technique. Under local anesthesia and CT guidance, a 3.5 inch 22-gauge spinal needle was inserted into the anterior aspect of the hip articulation. After the intraarticular location of the tip of the needle was confirmed with the return of a small amount of the contrast-enhanced injectate from the hub of the needle, the remainder of the 15 cc of the injectate, comprised predominantly of normal saline, nonionic iodinated contrast and lidocaine in conjunction with a minute amount of gadolinium-based contrast, was administered.

The patient was asked to rate their pain on a scale of 0-10 both prior to and following the administration of the lidocaine containing injectate. The patient reported preinjection and postinjection pain levels of 6 and 0 respectively.

The patient tolerated the procedure well, without complications, and following MR imaging of the left hip, was discharged from this institution in satisfactory condition.

CONCLUSION: Technically successful CT-guided pre-MRI left hip injection.
CPT: 27093, 77012-26

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