Table of Contents

Sample Medical coding Chart 1

INDICATION:

49-year-old male with HCC

TECHNIQUE:

Under direct ultrasound guidance a micropuncture needle was advanced into the common femoral artery and a microwire advanced. The needle was removed and a micropuncture sheath advanced over the wire. An 035 wire was advanced into the abdominal aorta and a 5 French sheath advanced over the wire. A SOS catheter was advanced into the celiac artery and an angiogram performed. Patient has a replaced left hepatic artery to the left gastric artery. The left hepatic artery was selected via the left gastric artery and an angiogram performed . A 3-D spin was performed. This showed that the caudate lobe tumor was not supplied from the left hepatic lobe artery. Next, the catheter was advanced into the common hepatic artery and an angiogram performed. A 3-D spin CT was performed. This showed supply to the caudate lobe tumor via the middle hepatic artery. This artery was substernally selected and an angiogram performed (36248). Bland embolization was then performed with 100 um Embozene particles . Follow-up angiogram demonstrated occlusion of flow within the artery. The sheath was removed, and hemostasis obtained with manual compression. The patient tolerated the procedure well. There were no immediate complications.

FINDINGS:

The initial ultrasound demonstrates a patent right common femoral artery. The celiac arteriogram demonstrates a variant anatomy with the left hepatic artery arising from the left gastric artery. Otherwise, the splenic and common hepatic arteries are unremarkable. Selective injection of the left hepatic artery with 3-D spin CT demonstrates perfusion of the left hepatic lobe and a portion of the middle hepatic lobe without evidence of supply to the caudate lobe. Selective injection of the common hepatic artery with 3-D spin CT demonstrates supply to the caudate lobe from a branch of the middle hepatic artery. Following embolization of the middle hepatic artery there is occlusion of flow.

CPT codes: 36247, 36248, 37243

36247 – This is variant anatomy, the LGA is a second-order vessel so that would make the replaced LHA a third-order vessel off of the LGA

36248– For the angiogram performed for Hepatic artery

37243 – Since the reason or the intent of the embolization was to infarct the tumor.

Sample Medical coding Chart 2

INDICATION:

Hepatic metastatic disease from neuroendocrine tumor

TECHNIQUE:

1% lidocaine was infiltrated within the skin overlying the right common femoral artery for local anesthesia. Ultrasound was performed for guidance and an image stored in the patient’s medical record. An 035 wire was advanced into the abdominal aorta and a 5

French sheath advanced over the wire. A sniper microcatheter and microwire was advanced into the right hepatic artery over a guidewire and an angiogram performed. The antireflux balloon was inflated and a repeat arteriogram acquired. The prescribed dose of 106.3 mCi of Yttrium 90 microspheres was infused according to protocol. The antireflux balloon was deflated and the microcatheter was removed. The sheath was removed, and hemostasis obtained with After the placement of a 6 French Angio-Seal.

The patient tolerated the procedure well. There were no immediate complications.

FINDINGS:

Ultrasound demonstrates a patent right common femoral artery. The celiac arteriogram demonstrates a patent GDA, left hepatic artery, middle hepatic artery and right hepatic artery. Selective injection of the right hepatic artery branch supplying segments 6 and 7 demonstrates tumor vascularity.

CPT code: 36247, 37243

Sample Medical coding Chart 3

INDICATION:

61-year-old female undergoing upcoming complex esophagectomy requiring empiric left gastric artery embolization for conduit conditioning.

TECHNIQUE:

The right common femoral artery was accessed with a micropuncture set using ultrasound. Ultrasound images were saved to PACS. The access was upsized to a 5F vascular sheath. Bentson wire a Mickelson catheter were advanced into the abdominal aorta. Celiac artery was selected (no code assigned for the celiac selection as the catheter was advanced more selectively), and celiac arteriogram was performed. Left gastric artery was selected (CPT code 36246) with Mickelson catheter and regular renegade microcatheter. Microcatheter was advanced into the proximal left gastric artery. Multiple left gastric arteriograms were performed. Proximal left gastric artery coil embolization was performed with two 3mm x 8cm and two 3mm x 4cm Concerto microcoils (37242). Completion left gastric and celiac arteriograms were performed.

FINDINGS:

Focused ultrasound demonstrated a patent right common femoral artery. Celiac artery demonstrated conventional hepatic, left gastric, splenic arterial anatomy. Left gastric artery was widely patent. Proximal left gastric artery coil embolization was performed. Ample coil free zone was left at the proximal left gastric artery to allow for clamping/ligation for upcoming surgery. Technically successful left gastric artery embolization. Completion arteriograms shows preserved flow within the hepatic and splenic arteries.

CPT codes: 36246, 37242

36246– for the gastric artery selected catherization

37242– Arterial Embolization other than hemorrage or tumor.

Sample Medical coding Chart 4

INDICATION:

68-year-old female with metastatic neuroendocrine carcinoma

TECHNIQUE:

1% lidocaine was infiltrated within the skin overlying the right common femoral artery for local anesthesia. Under direct ultrasound guidance a micropuncture needle was advanced into the common femoral artery and a microwire advanced. The needle was removed and a micropuncture sheath advanced over the wire. An 035 wire was advanced into the abdominal aorta and a 5 French sheath advanced over the wire. A

SOS catheter was advanced into the celiac artery (no code assigned for the celiac selection as the catheter was advanced more selectively) and an angiogram performed. A microcatheter was utilized to select the right hepatic artery (no code assigned for the right hepatic selection as the catheter was advanced still more selectively into the segment 6, 7, and 8 supply branch vessels)and an angiogram performed with 3-D spin CT. Due to the location of the cystic artery decision was made to perform segmental embolization. A microcatheter was advanced into the segment 7 artery (36247) and an arteriogram performed. Embolization was then performed utilizing 100-micron Embozene spheres until there was severe restriction of flow. Next, the microcatheter was advanced into the segment 8 artery (36248) and an angiogram performed. Embolization was then performed with the same size of spheres until there was severe restriction of flow. Next, the catheter was advanced into the segment 6 artery (36248) and arteriogram performed. Embolization was then performed (37243 – the intent of the embolization was infarction of the tumor) the same size of spheres until there was severe restriction of flow. A total of 2 vials of spheres were utilized during the embolization procedure. The microcatheter was removed. The sheath was removed, and hemostasis obtained with manual compression. The patient tolerated the procedure well. There were no immediate complications.

FINDINGS:

The initial ultrasound demonstrates a patent right common femoral artery. The celiac arteriogram demonstrates a conventional branching pattern with a patent splenic, left gastric, and common hepatic artery. The proper hepatic artery branching pattern is normal. Selective injection of the right hepatic artery demonstrates supply to multiple

hypervascular tumors. Injection of the segment 8, 7, and 6 hepatic arteries demonstrate supply to multiple tumors. Following embolization of these segmental hepatic arteries there is severe restriction of flow in each.

CPT codes: 36247, 36248, 36248, 37243