Artery Embolization- can you code this?

Artery Embolization- can you code this?
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What is Artery Embolization?

Embolization is a minimally invasive procedure performed by interventional radiologists. Artery Embolization is a procedure in which the blood supply of  the artery is blocked using a embolized agent. The main diagnosis to proceed for embolization is Hemorrhage or bleeding. Also to stop supply to tumor growing cells arteries of that part of body are blocked. For example, Uterine fibroid embolization is one common procedure done to remove fibroids from uterine body.
So, here I have some sample charts coded about artery embolization. You can also try to code this charts and if there is any corrections please post it in comment section.These tips are really important for Certification exams like CPC, you can go through sample CPC questions here which will surely help in clearing CPC exam.

CPC Practice Exam - Medical Coding Study Guide Please Click Here!



IR EMBOLIZATION INTRACRANIAL SPINAL
EXAM: IR EMBOLIZATION INTRACRANIAL SPINAL
PROCEDURE: Embolization of left posterior communicating artery aneurysm with coils.
HISTORY: 67 year-old female presenting with subarachnoid hemorrhage. Clinically her hemorrhage occurred 1 day ago. Previous angiographic evaluation has demonstrated a 7 x 5 mm aneurysm arising from the left internal carotid artery at the origin of the left posterior communicating artery. Endovascular treatment is requested.
TECHNIQUE: After informed consent was obtained and under general anesthesia the patient was prepped and draped in usual sterile fashion. A five French Cordis Envoy guide catheter was advanced into the left internal carotid artery via indwelling right-sided transfemoral sheath. Digital subtraction angiograms were obtained through the guide catheter to evaluate the configuration of the aneurysm. An Excelsior 10 microcatheter was subsequently advanced over a transcend 14 micro guidewire into the aneurysm. A first coil GDC 10, 6 x 20 was advanced entirely within the aneurysm and detached in good position. This was followed by 3GDC in decreasing sizes. Follow up angiograms were obtained after placement of each coil. The microcatheter and guide catheter were subsequently removed.
There were no immediate complications related to the procedure. Heparin was given in interarterial flush well as intravenous bolus. The left-sided transfemoral sheath was left for later removal.
FINDINGS: Left internal carotid artery angiogram demonstrates good opacification of the left middle cerebral artery , and the left anterior cerebral artery and via posterior communicating artery good opacification of the left posterior cerebral artery.
There is a 7 x 5 millimeter aneurysm at the origin of the left posterior communicating artery. Angiograms obtained after the final coil placement demonstrate good obliteration of the aneurysm, with a slight circulation of contrast around the neck
and distal contrast stagnation .
INTERPRETATION LOCATION: Main Campus
Successful endovascular treatment of left posterior communicating artery aneurysm with coils. A first follow-up angiogram is recommended in three months.

CPT - 61624, 36224, 75898, 75898-59, 75894


CEREBRAL ANGIOGRAM AND EMBOLIZATION OF A LEFT OCCIPITAL LOBE:
ARTERIOVENOUS MALFORMATION.
INDICATION: Arteriaovenous malformation which presented with
hemorrhage. Preoperative embolization.
ANESTHESIA: General anesthesia.
COMPARISON EXAM: Diagnostic cerebral angiogram performed at the time of his initial clinical presentation from 3/30/2014.
EMBOLIC AGENT: Onyx 18 liquid embolic agent with 1 mL delivered into a left anterior cerebral artery pedicle and 0.2 mL delivered in the left posterior cerebral artery pedicle.
CONTRAST DOSE: 250 mL of Isovue 250 non-ionic intravenous contrast.
HEPARIN: 5000 units of IV heparin was administered during the procedure.
FLUOROSCOPIC TIME: 112.1 minutes.
DOSE: 5608 mGy.
TECHNIQUE: The right groin was prepped and draped in the usual sterile fashion.
1% lidocaine was utilized for local anesthesia.Micropuncture technique was utilized to cannulate the right common femoral artery and a 6-French sheath was advanced over a guidewire and connected to a heparinized flush system. After placement of the sheath, 5000 units of IV heparin was administered for anticoagulation purposes. DSA was obtained through the sheath showing the arteriotomy site to be of the above the right common femoral artery bifurcation.
Through the sheath, a 4-French catheter was navigated over a guidewire into the following vessels:
Left vertebral artery. Left internal carotid artery. Biplane digital subtraction angiography was obtained in the neck distally and in the head in each location.An arteriovenous malformation is identified in the anteromedial left occipital lobe. Arterial inflow is from branches of the left posterior cerebral artery as well as a dominant arterial pedicle from the left anterior cerebral artery. A 4-French catheter was removed from the left internal carotid artery over an exchange length guidewire and a 6-French Neuron guiding catheter was advanced into the proximal petrous left internal carotid artery and connected to a heparinized saline flush system. Under roadmapping visualization, an attempt was made to advance a Scepter XC 4 mm x 10 mm balloon over a guidewire into the distal left anterior cerebral artery pedicle, but this was unsuccessful.This catheter was removed. A Marathon microcatheter was advanced over a microguidewire under roadmapping visualization into the distal left anterior cerebral artery pedicle and biplane DSA was obtained through the microcatheter in the distal left anterior cerebral artery. This showed the arterial venous malformation. The microcatheter tip is past any normal branches. The AVM nidus is well seen as is venous drainage into the vein of Galen.
Under roadmapping visualization, approximately 1 mL of Onyx 18 liquid embolic agent was utilized to embolize the AVM from this distal left anterior cerebral artery location. Postembolization angiography through the guiding catheter in the left internal carotid artery demonstrates a significant percent occlusion of the arteriovenous malformation. Biplane DSA was obtained through the guiding catheter in the left internal carotid artery, which refluxed into the left posterior cerebral artery through the posterior communicating artery, showing minimal residual AVM being fed by left posterior cerebral artery branches. A different Marathon microcatheter was advanced over a microguidewire through the guiding catheter across the posterior communicating artery into the left posterior cerebral artery and biplane digital subtraction angiography was obtained through the microcatheter in four separate left posterior cerebral artery branches. Supraselectively, this microcatheter was advanced into the largest arterial feeder and this vessel was embolized to occlusion with some penetration of the nidus, utilizing Onyx 18 liquid embolic agent,
approimately 0.2 mL. The microcatheter was removed. Global postembolization DSA was
obtained through the left internal carotid artery and left vertebral artery showing near complete occlusion of the AVM with no evidence of extravasation or distal thromboembolic filling defects.
A radial arterial line was placed by anesthesia prior to the procedure and anesthesia was instructed to keep the patient's systolic blood pressure less than 120 during and after the procedure. The guiding catheter was pulled back into the left internal carotid artery and DSA was obtained in the neck showing no injury to the left internal carotid artery. The guiding catheter was removed and hemostasis was obtained using a StarClose percutaneous closure device.
FINDINGS:
Left vertebral artery: The left vertebral artery is normal in caliber in the neck and intracranially. The basilar artery is well-visualized and normal in appearance. There are a few branches of the left
posterior cerebral artery supplying flow to an AVM with venous drainage into the vein of Galen.
Left internal carotid artery: The left anteromedial occipital lobe AVM is again identified with a large arterial pedicle from the distal pericallosal left anterior cerebral artery supplying flow to the
majority of the nidus with venous drainage ultimately to the vein of Galen. Distal left anterior cerebral artery: With the microcatheter at the level of the AVM nidus, only the nidus opacifies with contrast. No
normal branches are seen. Left posterior cerebral artery branch 1, 2, 3, and 4: Superselective
microcatheter investigation of each of these 4 branches shows arterial inflow to the AVM. The largest branch was utilized for superselective Onyx embolization.
IMPRESSION:
1. Anteromedial left occipital lobe AVM.
2. Successful embolization of two pedicles to this AVM with near complete occlusion of the AVM.
3. The images were reviewed with Dr. Adam Hebb, who is planning a neurosurgical resection tomorrow.
4. The patient will be observed in the neurointensive care unit overnight and will be maintained with systolic blood pressure less than 120.

CPT- 61626-LT, 36224-LT, 36228-LT, 36228-59,LT, 75894-LT, G0269-59


EXAM: 1) HEPATIC ARTERIOGRAM - PRE-RADIOEMBOLIZATION
2) SMA ARTERIOGRAM
3) GASTRODUODENAL ARTERIOGRAM WITH EMBOLIZATION
4) RIGHT HEPATIC ARTERIOGRAM
5) RIGHT COMMON FEMORAL ARTERY ARTIOGRAM
INTERPRETATION LOCATION: Main Campus
CLINICAL INDICATION: Colon cancer metastatic to the liver.
PROCEDURE: Written informed consent was obtained after a thorough discussion with the patient and her daughters about the risks including, but not limited to, infection, bleeding, irreversible injury to the aorta, visceral arteries and/or organs, non-target embolization, need for an additional procedure and a remote risk of surgery, ICU admission and death.
The patient received moderate conscious sedation using IV Versed and Fentanyl under the continuous care and cardiopulmonary monitoring by a Radiology Nurse.
Ultrasound guided access: US evaluation showed a patent right CFA. There is minimal atherosclerosis. Images were saved to PACS. The right groin was prepped and draped in a sterile manner. Using 1% lidocaine without epinephrine, local anesthesia was performed at the vascular access site. Right lower extremity arterial access was then obtained with a 21 gauge-4 cm needle with US guidance and micropuncture set. Through the micropuncture 4-F catheter and over an 0.035 inch guidewire a 5-F sheath was then placed.
A Mickelson catheter was used to select the celiac and superior mesenteric artery under fluoroscopic guidance. A selective celiac abd Superior mesenteric artery digital subtraction arteriogram (DSA) were performed.
A microcatheter and 0.018 inch glidewire was advanced into the Mickelson catheter placed into the Celiac artery, subselective DSA's of the right hepatic arteries and gastroduodenal were subsequently performed.
FINDINGS:
VESSELS INJECTED: Celiac, common hepatic, right hepatic, gastroduodenal, and superior mesenteric arteries.
SUPERIOR MESENTERIC ARTERY: Normal origin and patency. Minimal ahterosclerotic stenosis in proximal ilial branches. There was no supply to the liver. Venous phase in normal.
CELIAC ARTERY: Normal origin and patency. No focal stenosis or occlusion. Venous phase is normal
COMMON HEPATIC ARTERY: Normal origin and patency with diffuse intrahepatic arterial irregularity. There is a focal stenosis at the left hepatic artery origin with vessel ectasia.The gastroduodenal artery was identified and patent. No accessory vessels
were appreciated.
RIGHT HEPATIC ARTERY: Normal origin and patency. After manipulation of the cathter, a focus of persistent irregular focus was noted near a genu in the left hepatic artery that may be a focal dissection or small aneurysm. There was limited reflux into the left HA. Tumor blush was identified in the right hepatic lobe wiht diffuse hepatic artery irregularity consistent with post chemotherapy changes.
Gastroduodenal artery: Normal caliber and within 2 cms of the hepatic artery bifurcation. No collateral filling of the liver or right HA.
GASTRODUODENAL ARTERY EMBOLIZATION: Due to the proximity of the GDA to the RHA, it was necessary to coil embolized the vessel for bowel protection. The microcatheter was placed into the gastroduodenal artery, and several 3-5 mm Tornado coils were used to embolize the gastroduodenal artery.
Liver Lung Shunt Study: The microcatheter was placed back into the right hepatic artery, and Technetium 99-m MAA was injected for a subsequent liver-to-lung shunt perfusion scan. 2.2 mCi of Tc99m MAA was injected.
Following the infusion, the microcatheter, Simmons-1 and all other equipment used in the delivery of the MAA was placed into a separate trash container designated for radiation waste.
RIGTH COMMON FEMORAL ARTERIOGRAM: The catheter and sheath were removed, and an arteriogram was performed of the right common femoral artery, which demonstrated favorable anatomy for closure device placement. An Angioseal device was used for closure, which provided adequate hemostasis. The sheath site was dressed in a sterile manner.
CONSCIOUS SEDATION: 1 hour, 19 minutes
FLUOROSCOPY TIME: 16 minutes
EXPOSURES: 213
DOSE AREA PRODUCT: 6014 uGym2
TOTAL DOSE: 272.4 mGy
1. Pre-radioembolization arteriogram with injection of technetium MAA for evaluation of liver/lung shunt. The nuclear medicine scan will be dictated under a separate accession number.
2. Left hepatic artery stenosis and ectasia or small dissection.
3. Coil embolization of the gastroduodenal artery.

CPT- 37243, 75726-59, 75726-59, 75774, 75774-59, 75774-59


IR EMBOLIZATION INTRACRANIAL SPINAL
CLINICAL INDICATION: 71 Year Old (F) presented with subarachnoid hemorrhage. A four-vessel angiogram demonstrated a large aneurysm arising from the anterior communicating artery complex and smaller aneurysms of the cavernous left internal carotid artery and communicating segment of the right internal carotid artery. Endovascular treatment of the anterior communicating artery aneurysm is requested.
PROCEDURE: Embolization of anterior communicating artery aneurysm with coils.
TECHNIQUE: After informed consent was obtained and under general anesthesia the patient was prepped and draped in usual sterile fashion. A right sided 5 French femoral sheath was exchanged for a 6 French 80 cm long shuttle. The shuttle was advanced into the left common carotid artery over a JB one slip catheter. A 5 French Navien guide catheter was advanced into the distal extracranial left internal carotid artery where digital subtraction angiograms were obtained over the intracranial circulation in multiple projections to evaluate the configuration of the aneurysm. An Excelsior 10 microcatheter was subsequently advanced over a Synchro 14 micro guidewire into the aneurysm. A first coil Microplex 10, 7x 20 was advanced entirely within the aneurysm and detached in good position. This was followed by 8Microplex coils in decreasing sizes. Follow up angiograms were obtained after placement of each coil. The microcatheter and guide catheter were subsequently removed.
There were no immediate complications related to the procedure. Heparin was given in interarterial flush well as intravenous bolus. The right sided transfemoral sheath was left for later removal.
FLUOROSCOPY TIME: 63.0 minutes.
EXPOSURES: 579
CONTRAST: 70 mL Omnipaque 300
FINDINGS: Left internal carotid artery angiogram demonstrates good opacification of the left middle cerebral artery , and the left anterior cerebral artery . There is a 9 x 20 mm aneurysm at the left side of the anterior communicating artery complex.
The aneurysm has a very wide neck. Angiograms obtained after the final coil placement demonstrate good obliteration of the aneurysm, with a minimal neck remnant.
INTERPRETATION LOCATION: Main Campus
Successful coil embolization of anterior communicating artery aneurysm with coils. A first follow up angiogram is recommended in six months.

CPT- 61624 36224 75898-26 75894-26


MESENTERIC ARTERIOGRAM WITH EMBOLIZATION
INDICATION/DIAGNOSIS: GI bleed with continued losses following
embolization earlier today.
POSTOPERATIVE DIAGNOSIS: Same
CONTRAST: 120 mL Isovue 250
SEDATION: General endotracheal anesthesia was provided by anesthesia service.
PROCEDURE: With the patient in a supine position, the left groin was prepped and draped sterilely. The left groin was selected due to recent placement of an Angio-Seal at the right groin. 1% lidocaine was given as local anesthetic. Access was gained into the left common femoral artery with a micropuncture set. A 5 French sheath was placed at the access site. Through this, a 4 French glide C2 catheter was advanced with an angle-tip Glidewire to select the celiac artery. The catheter and guidewire were advanced to the common hepatic artery.
Digital subtraction arteriography was then performed. This showed occlusion of the celiac artery proximally at the site of the most superior embolization coil. A proximal gastroduodenal artery branch
was seen to continue to fill just proximal to the coiled. This communicated with the left hepatic artery but also are dictated more inferiorly to contribute to a blush at the second portion of the
duodenum. Through the C2 catheter, a velocity microcatheter and fathom microwire were advanced and were used to select this branch. These were advanced to the level of communication with the left hepatic artery so that no backfilling of this region would occur from the left hepatic artery. A 2 mm x 4 cm Ruby microcoil was deployed in this artery, with care not to extend the coil into the left hepatic artery.
The coil was extended back into the gastroduodenal branch, successfully occluding flow to the duodenal collateral. Additionally, to further occlude the gastroduodenal artery, with the microcatheter
tip in the first branch, a 6 mm x 12 cm Ruby soft microcoil was deployed, coiling first in the branch and then extending into the gastroduodenal artery to its origin. The coil did not extend into the
common hepatic artery. Repeat angiography with the C2 catheter and the common hepatic artery showed no further filling of the gastroduodenal artery, nor was there continued blush at the level of the second portion of the duodenum.
Next, the C2 catheter was used to select the superior mesenteric artery. Digital subtraction arteriography showed extravasation at the level of the second portion of the duodenum through a proximal duodenal branch. Additional third order selective arteriography of 2 duodenal branches was performed. On selection of the more inferior of the 2 arteries, extravasation was seen to be fed by this branch. The velocity microcatheter was advanced peripherally towards the site of extravasation, and embolization was performed with a 3 mm x 15 cm Ruby soft microcoil. Repeat angiography confirmed stasis and no further extravasation.
In preparation for closure, a left common femoral arteriogram was performed, confirming the sheath to be within the left common femoral artery. Closure was then performed with a Starclose device without
complication. At the conclusion of the procedure, the patient was transferred to the intensive care unit, remaining intubated.
SPECIMENS: None
FLUOROSCOPY TIME: 18.4 minutes of fluoroscopy time was used.
ESTIMATED BLOOD LOSS: 10 mL
COMPLICATIONS: None
IMPRESSION:
1. Persistent extravasation seen at the level of the second portion of the duodenum. Contributing branches from the gastroduodenal artery and duodenal branch off of the superior mesenteric arterial
circulation were successfully selected and embolized with coils as above.

CPT- 37242, 36246, 36245-59, 75726-59, G0269

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