Vol. 15 •Issue 10 • Page 10
Coding Corner
Coding Interventional Radiology Studies
(Editor’s note: This is Part 1 of a two-part column. Test your skills and see if you can assign the correct codes for the following case study. Part 2, the code assignments and rationale, will be featured in the June 6 issue.)
As you review the following, note the phrases in boldface type. These can help you arrive at the appropriate CPT code assignments. Also note the phrases in underlined boldface type, which will help you arrive at the appropriate ICD-9 code(s) for the studies performed.
Case Study: Bilateral Selective Renal Angiography Followed by Supraselective Studies of the Right Renal, Selective Study of Accessory Right Renal Artery
This is a 75-year-old gentleman with a 2-year history of recurrent gross hematuria. Evaluate for possible AVN. After discussing the risks and benefits of the procedure with the patient, the patient consented to proceed.
The right groin was sterilely prepped and draped under local anesthesia. The right common femoral artery was punctured with a 21-gauge needle. After wire and dilator exchanges, a 4-French sheath was placed. An abdominal aortogram was performed with an Omniflush catheter. Abdominal aortogram demonstrates two renal arteries on the right, single renal artery on the left. The patient has diffuse atherosclerotic disease. Surgical clips are noted along the anterior midline secondary to previous abdominal surgery.
The left renal artery was selected with a size Omni II catheter. Multiple selective left renal artery arteriograms were performed demonstrating normal renal artery arterial anatomy with no evidence of aneurysmal dilatation. No strictures or focal areas of stenoses. There is normal tapering of the vessels. There is no filling defects noted in the parenchymal phase and the venous phase demonstrates a single renal vein.
The main right renal artery was then catheterized with a size Omni III catheter. Multiple selective right renal arteriograms were performed in different projections. There is no stenosis noted. No beading or abnormal contour is noted of the renal arteries. The parenchyma is stilled except for the upper pole which superiorly is supplied by the accessory renal artery. The patient appears to have a small aneurysm in the infrarenal aorta as well, measuring approximately 2.2 cm. This is the filled portion and is best evaluated on CT.
Using a glide Cobra catheter, both the anterior and posterior branches of the main renal artery of the right were cannulated and selective second-order arteriograms were performed. Again, the arterial anatomy is normal. There is no evidence of an arterial venous malformation. No persistent blush, no early blush. The parenchyma appears to fill smoothly and homogeneously. The right testicular artery was identified and filled normally.
The accessory right renal artery was then selected, again using the size Omni III catheter. Multiple images were acquired of the accessory right renal artery. The accessory renal artery supplies the upper pole of the right kidney. Again, no evidence of abnormal contour of the vessels. There is no aneurysmal dilatation, no strictures, no abnormal blushes were noted. Incidental note is made of vascular spasm in the posterior inch of the right main renal artery during many of the exams, but this is definitely a spasm and not optic stricture, as it was not on the initial selective arteriogram.
Loss of a first-degree branch of the accessory artery supplying in the region of the mid to upper pole on the right. There is a slight irregular contour of this branch vessel. While there is no venous blush noted, there is no quick venous direct outflow noted such as a fistula. A small AVN in this area cannot be excluded. This is actually seen on multiple views on review of this selective study. The patient may benefit from repeat selective accessory artery arteriogram and coiling of this area. The remainder of the study is unremarkable. Images of the collecting system were obtained. The right renal collecting system is moderately dilated. This may be secondary to the fact that the patient currently has active gross hematuria, and this may be secondary to some mild obstructive symptoms secondary to blood clot. No filling defects are noted. At the UPJ, there is also a shelf-like filling defect noted and again, this may be secondary to blood clot vs. a wall lesion.
Impression
Dilated collecting system on the right. A collecting system lesion, particularly in the region of the UPJ cannot be excluded and a repeat retrograde examination and ureteroscopy may be helpful.
If the repeat evaluation of the renal pelvis remains negative, I would recommend a repeat selective accessory right renal arteriogram to re-evaluate this small focus of abnormal vessel off the second order branch of the accessory artery. This may represent a small AVN and directed embolization may be helpful.
Code Assignments and Rationale
Test your skills and see if you can find the correct codes. Check back with ADVANCE in the June 6 issue for the coding assignments and rationale for this case study.
Bernie Van Someren is a senior health care consultant with Medical Learning Inc. (MedLearn), St. Paul, MN.
