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Here is
your ZHealth Coding Newsletter for June
2007
Bronchial Artery Embolization Q &
A
Below is a recent
question submitted by a ZHealth
Online member – and Dr. Zielske’s reply. If you’re not
already a subscriber, try out ZHealth
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Coding
Question:
Our
interventional radiologist did a bronchial artery
embolization yesterday and I have never coded something
like this. Please tell me if you agree with my codes
and/or what corrections you would make.
Access was
obtained via the rt common fem artery, A 8 Fr sheath was
placed. A 5 Fr multi-side hole catheter was placed in
the proximal descending thoracic aorta. A large volume
rapid sequence imaging aortogram was performed. The
aortogram shows clear visualization of multiple
intercostal
bronchial arteries. There appears to be a common trunk
bronchial artery at the level of the bifurcation
supplying both the right and left main bronchial
arteries. There is an additional rt bronchial artery,
which appears to arise from a secondary origin from the
aorta.
There also
appears to be some intercostal bronchial arteries
arising from the lt at approximately the level of T6
through T8. The diagnostic catheter
was exchanged for a 5 Fr cobra catheter. This was used
to selectively catheterize the common trunk of the main
bronchial artery supplying both the rt and lt. A
selective bronchial arteriogram was
performed through this catheter.
Following this a microcatheter was advanced in a coaxial
fashion through the 5 Fr catheter into the rt bronchial
artery. A subselective rt bronchial arteriogram was
performed. Transcatheter particulate embolization was
carried out with a mixture of 3 to 500 and 5 to 700
micron PVA particles. Embolization was performed to a
point where there was near complete
cessation of flow into he selected
bronchial artery. The left main
bronchial artery was selected. A subselective left
bronchial arteriogram was then performed. The
subselective bronchial arteriograms show a normal
pattern of vascularity within the bronchial tree. No
dangerous collaterals are identified. Transcatheter
particulate embolization was carried out on the left
similar to the right. Following this,
a secondary right bronchial artery was initially
selected with a 5 Fr catheter. Again, the microcatheter
was advanced in a coaxial fashion through the diagnostic
catheter. A selective secondary right bronchial
arteriogram was performed. Again no dangerous collateral
are identified. There is a fairly typical branching
pattern of the accessory right
bronchial artery. Transcatheter particulate embolization
was carried out in standard fashion. Final angiograms
via the microcatheters show complete cessation of flow
in the bronchial arteries.
Following this,
in attempts to locate additional left bronchial
arteries, three selective left intercostal arteriograms
were performed. There are some paired intercostals,
which are supplied from common trunks. No additional
significant bronchial flow is identified to the left
lung. The> access catheter was removed. Hemostasis
was achieved with placement of a StarClose device.Here
are the codes I came up with:75726 main trunk, 36216-rt
rt bronchial off trunk, 75774, 36218-lt lt bronchial off
trunk, 75774, 36215-59-rt rt bronchial off aorta,
75726-59-rt, 36215-59-lt times 3 lt
intercostal off aorta, 75726-59 times
3, 37204-rt embolize rt bronchial, 75894-rt, 37204-59-lt
embolize lt bronchial, 75894-59-lt, 75898 times 3, G0269
vascular closure device.
Dr. Z’s
Answer:
This is a fairly
typical bronchial embolization case; however in this
case bilateral embolization was performed. Usually the
pulmonologist localizes the bleeding site to one side or
lobe of the lung for embolization. The lungs are treated
as separate surgical sites, unless embolized from a
single vessel supplying both. In this case the left was
selectively catheterized off a common trunk, as was the
right with additional right accessory bronchial selected
separately off the aorta. Three intercostal arteries
(spinals) were also selected and imaged on the left
without further intervention.
I would code
catheter placements in the main trunk as 36216 and
36218. (I bet the MD actually was third order selective
on the right, bypassing the artery to the cervical
spinal cord, however this was not
documented). The other catheter
placements are all 1st order, one on the right and three
on the left, coded 36215-59 x 4 due to edits with 36216.
The embolizations would be coded 37204 and 75894 on the
left and the same on the right. Follow up imaging is
documented from all three vessels embolized but would
only be coded per surgical site so 75898 x 2. The
initial imaging would be coded as a combination of
visceral, additional imaging and spinal imaging codes.
75726 for the initial common trunk bronchial
angiography, 75774 x 2 for the
additional selective imaging beyond basic of the right
and left bronchials super-selectively, 75726 for the
accessory right bronchial imaging, 75705 x 3 for the
three left intercostal arterial imaging
procedures. The initial thoracic
aortic imaging is bundled into the initial visceral
imaging code. So, I would submit, based on this
documentation, 36216, 36218, 36215-59 x 4, 75726 x 2,
75774 x 2, 75705 x 3, 37204 x 2, 75894 x 2 and 75898 x 2
and G0269. Modifiers as needed per you local payors.
Hope this helps.
Again, most
bronchial embolizations are unilateral, despite
embolizing multiple vessels on the same side. This case
actually treats separate bleeding sites in two separate
lungs via two separate bronchial arterial supplies.
Also, I would code the injection and imaging of
intercostal arteries as spinal angiography, not
visceral, as no viscera would be expected to be seen
from these injections (in some circumstances there can
be intercostal-bronchial communications in long standing
bronchial disease, but this is not usually the case) and
none was identified. Spinal angiography also reimburses
less than visceral angiography. I would stay on the
conservative side of coding/reimbursement in such
cases.
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Learn a LOT
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Seminars
The next ZHealth
Coding Seminar will be held in Nashville, TN, Sept
11-14, at the Gaylord Opryland
Hotel & Convention Center. If you haven’t
had a chance to attend one of our
Interventional Radiology & Cardiology Coding
programs yet this year, you can make your reservation(s)
now. We’ll also be in Las Vegas at the Wynn in November and
in Scottsdale, AZ at the FireSky Resort
& Spa next February (2008).
Web Seminar CD’s Now Available : A Great
Addition to Your Coding Reference Library
ZHealth held
its first Web Seminar June 5th : Understanding
Dialysis Access Coding From Insertion to
Maintenance, and we now plan to offer a series of
interventional radiology, cardiology, and vascular
surgery coding seminars on the web beginning this
September. More information will be coming soon. If you
missed the first one, you
can purchase the course (and the outline) on CD –
and still earn CEU’s. Find out more.
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