Transcatheter arterial embolization for the management of iatrogenic and blunt traumatic intercostal artery injuries

Abstract

Management of hemorrhage in trauma patients can be achieved by open surgical repair or endovascular methods. The authors present their experience with transcatheter arterial embolization of iatrogenic and blunt traumatic intercostal artery injuries associated with hemothorax and clinical deterioration. They conclude that this therapy is minimally invasive, safe, and reliable in the hands of a skilled interventionalist. Coding for this procedure is subject to component coding guidelines for the use of catheters, imaging, and intervention. Because the intercostal arteries are located above the diaphragm, each will generally be reported by CPT code 36215 as a first-order catheterization regardless of the initial artery punctured. If multiple intercostal arteries require evaluation or treatment, or both, each vessel generally occupies a separate vascular family and therefore necessitates separate and distinct catheter coding. In one instance, the thyrocervical trunk required embolization, which is second order (CPT code 36216) or third order (36217), based on side and aortic arch anatomy from a femoral approach, or first order (36215) from an ipsilateral arm access. The musculophrenic artery is a branch off the internal mammary and selective cannulation is third order (CPT code 36217) from a femoral approach and second order (36216) from an ipsilateral arm puncture. If a lumbar or inferior phrenic artery (as reported in the article) is involved, catheter manipulation below the diaphragm uses CPT codes 36245, 36246, or 36247 for first-, second-, and third-order selection, respectively. Imaging generally begins with an arch aortogram that includes a description of the great vessel origins (CPT code 75650) or descending thoracic aortography (CPT code 75605), or both. Angiography of each intercostal artery that is selectively cannulated may be reported by CPT code 75706. Selective imaging of the internal mammary artery to evaluate the musculophrenic arterial tree is reported by CPT code 75756. If the inferior phrenic artery is a branch off the aorta, CPT code 75774 is appropriate for further selective imaging, whereas CPT code 75726 is more fitting when it branches off the celiac arterial family. The imaging codes listed above assume that there is no prior diagnostic angiogram in this clinical condition. Even a computed tomography scan cannot provide the detail required for this type of procedure. This is important because version 10.3 of the National Correct Coding Initiative created an edit on October 1, 2004, in the policy manual that bundled imaging with intervention. Therefore, one must dictate into the operative report if no prior angiography was done in a given clinical situation, which then allows addition of the -59 modifier to the imaging codes for appropriate reimbursement. Embolization implies percutaneous placement of a thrombogenic material through a selective catheter in an attempt to occlude an aneurysm, arteriovenous malformation, or bleeding site. There is no alteration in the coding based on the agent used to induce clot. In addition, most embolization procedures are followed by contrast angiography to evaluate the adequacy of the thrombosis. CPT codes 37204 and 75894 describe the transcatheter embolization procedure. The code is reported once per field. In this example, each intercostal artery would generate its own coding. When the occlusive material is in place, follow-up angiography to assess for ongoing hemorrhage is reported by CPT code 75898 for each operative field treated as well.