Ask Dr. Z

Can you take a look at this case for me? I have seen a few of these, and I am not sure if I am coding these correctly. The codes that I am coming up with are 76937 (ultrasound), 36246 (left internal iliac), 75736 (left internal iliac), 37204, 75894, 75898 (embolization), G0269 (Mynx), 36245 (right L3 lumbar artery), 36245, and 36248 (left L3 artery including 2 feeding ascending lumbar pathways). Please let me know if I am close and thank you for your help.  Here is the procedure:

Reason for Exam: Abdominal aneurysm.  Findings Exams: Abdominal aortogram with selective left internal iliac arteriogram disease (3rd order), embolization non-neuro, placement of vascular closure device. History: Abdominal aortic aneurysm, status post EVAR with type II endoleak and enlarging aneurysm sac Technique: Intravenous conscious sedation with Fentanyl and Versed was administered in my presence. The patient was continuously monitored by a special procedures nurse for a duration of one hour and 30 minutes. Fluoroscopy time: 28 minutes. The left groin was prepped and draped with the maximum sterile barrier technique. Ultrasound was used to identify a patent left common femoral artery and image recorded in PACS. Using ultrasound localization, sterile technique, and lidocaine anesthesia, a 21 gauge needle was placed into the upper left superficial femoral artery and exchange made for a 5 French sheath. Aortogram, selective arteriography, and intervention is as detailed below. Findings: Abdominal aorta: AP aortography shows no evident type I endoleak, however delayed imaging shows prominent flow through the left ascending lumbar artery with retrograde flow into the left L3 lumbar artery and perfusion to the endoleak cavity. The inferior mesenteric artery fills via the marginal artery, but does not course back to the aneurysm sac and is not felt to be a contributor to the endoleak. Both renal arteries show mild stenoses with some irregularity of the main renal arteries which may be due to fibromuscular disease. Left internal iliac artery: Selective injection shows prominent ascending lumbar artery which bifurcation shortly after its origin and filling of a large L3 lumbar artery which is patent to the endoleak cavity. This felt to be the etiology for the endoleak. Catheterization of the ascending lumbar artery with negotiation of the multiple turns required to catheterize the endoleak cavity was quite difficult, but eventually was achieved with a Progreat catheter. Injection within the endoleak cavity confirms appropriate placement with outflow via the right L3 lumbar artery. The endoleak cavity was then filled with multiple 8 and 10 mm Nester microcoils. Catheter was negotiated into the proximal right L3 lumbar artery and occlusion done with 6 mm microcoils. The left L3 lumbar artery as well as 2 feeding ascending lumbar pathways were occluded with multiple 2 mm to 4 mm Nester microcoils. Completion and spot films show no residual filling to the endoleak cavity. The left femoral access site was assessed and closed with the Mynx closure device. Good hemostasis was achieved. Impression: 1. Type II endoleak via the left ascending lumbar and retrograde flow in left L3 lumbar artery. Successful coil occlusion of the endoleak cavity and feeding arterial pathway was done as detailed above.