Endovascular spinal arteriogram

[BEVERLYL_66037]

Hello,
I need another set of eyes. can you possibly explain why he would see 24 units? I want to make sure I am explaining the differences
my provider selected:

1. 36215 X24 units
2. 36245 X3 units
3. 75705 X27 units
4. 76937 X1 units

I found

1. 76937 X1 unit
2. 36217 X1 unit
3. 75705 X18 units
4. 36215 X14 units
5. 36245 X3 units

POSTOPERATIVE DIAGNOSIS: Spinal dural arteriovenous fistula.

PROCEDURE PERFORMED:

1. Introduction of needle and catheter into the right proximal femoral artery under continuous ultrasound guidance with storage of an image.
2. Right supreme intercostal arteriogram.
3. Right T5 segmental arteriogram.
4. Right T6 segmental arteriogram.
5. Right T7 segmental arteriogram.
6. Right T8 segmental arteriogram.
7. Right T9 segmental arteriogram.
8. Right T10 segmental arteriogram.
9. Right T11 segmental arteriogram.
10. Left T5 segmental arteriogram.
11. Left T6 segmental arteriogram.
12. Left T7 segmental arteriogram.
13. Left T8 segmental arteriogram.
14. Left T9 segmental arteriogram.
15. Left T10 segmental arteriogram.
16. Left T11 segmental arteriogram.
17. Left L2 segmental arteriogram.
18. Right L1 segmental arteriogram.
19. Left L1 segmental arteriogram.

ANESTHESIA: General endotracheal.

INDICATIONS FOR PROCEDURE: This is a 70-year-old gentleman who presents with bilateral leg weakness. MRI of the thoracic spine raises concern for a vascular abnormality of the spine. I was asked to perform a spinal angiogram to further characterize this lesion. Risks and benefits of the procedure were discussed with the patient prior to the procedure. Risks include, but not limited to vessel injury, hematoma, stroke, coma or death. The patient and family understood the risks, benefits of the procedure and elected to proceed. All their questions were answered. Informed consent was obtained. No guarantees were made.

DESCRIPTION OF PROCEDURE: The patient was brought to the angio suite and positioned supine on the angio table. Following induction of general anesthesia, the patient was endotracheally intubated. SSEP and EEG monitoring was established and remained at baseline throughout the procedure. A timeout was performed in accordance with hospital protocol. Under continuous ultrasound guidance, the right femoral artery identified and noted to be patent. Using modified Seldinger technique micropuncture needle was used to obtain access to the right femoral artery, and a 5-French sheath was placed under continuous ultrasound guidance with storage of an image. We then prepped and advanced a 5-French Mikaelson catheter over a 0.035 Glidewire. Wire and catheter combination were then tracked to the arch, where the catheter was then used to selectively catheterize the bilateral T5, bilateral T6, bilateral T7, bilateral T8, bilateral T9, bilateral T10, bilateral T11, bilateral L1, left L2, and right supreme intercostal artery. Selective injection was performed with the catheter positioned in each of these vessels with filming in the PA view using digital reconstruction. Once the right T7 segmental artery was demonstrated to supply a spinal dural arteriovenous fistula, we then advanced the microwire and microcatheter combination to selectively catheterized the right T7 to perform selective microcatheter injections to further characterize the fistula. We then turned our attention to closure. The sheath was then removed and exchanged for a 5-French Mynx device that was then deployed to achieve excellent hemostasis. The patient was then transferred to the recovery area in stable condition having tolerated the procedure well. It should be noted I was present throughout the procedure from puncture to final closure and immediately available throughout.

ANGIOGRAPHIC FINDINGS:

1. Right groin ultrasonography: Right femoral ultrasonography demonstrates a pulsatile and patent right femoral artery. This was used to guide placement of the sheath under continuous ultrasound guidance with storage of an image.
2. Right supreme intercostal arteriogram: Selective injection of the right supreme intercostal artery demonstrates the vessel and its distal branches fill out well. There is no evidence of supply to arteriovenous fistula or spinal artery noted on this injection.
3. Left L2 segmental arteriogram: Selective injection of the left L2 segmental artery demonstrates the vessel and its distal branches fill out well. There is no evidence of supply to arteriovenous fistula or spinal artery noted on this injection.
4. Left L1 segmental arteriogram: Selective injection of the left L1 segmental artery demonstrates the vessel and its distal branches fill out well. There is no evidence of supply to arteriovenous fistula or spinal artery noted on this injection.
5. Right L2 segmental arteriogram: Selective injection of the right L2 segmental artery demonstrates the vessel and its distal branches fill out well. There is no evidence of supply to arteriovenous fistula or spinal artery noted on this injection.
6. Right T5 segmental arteriogram: Selective injection of the right T5 segmental artery demonstrates the vessel and its distal branches fill out well. There is no evidence of supply to arteriovenous fistula or spinal artery noted on this injection.
7. Right T6 segmental arteriogram: Selective injection of the right T6 segmental artery demonstrates the vessel and its distal branches fill out well. There is no evidence of supply to arteriovenous fistula or spinal artery noted on this injection.
8. Right T7 segmental arteriogram: Selective injection of the right T7 segmental artery demonstrates the vessel and its distal branches fill out well. There is supply to a spinal dural arteriovenous fistula from this injection.
9. Right T7 dural arteriovenous fistula procedure: Microcatheter injection further delineates the anatomy of the fistula.
10. Right T8 segmental arteriogram: Selective injection of the right T8 segmental artery demonstrates the vessel and its distal branches fill out well. There is no evidence of supply to arteriovenous fistula or spinal artery noted on this injection.
11. Right T9 segmental arteriogram: Selective injection of the right T9 segmental artery demonstrates the vessel and its distal branches fill out well. There is no evidence of supply to arteriovenous fistula or spinal artery noted on this injection.
12. Right T10 segmental arteriogram: Selective injection of the right T10 segmental artery demonstrates the vessel and distal its branches fill out well. There is no evidence of supply to arteriovenous fistula or spinal artery noted on this injection.
13. Right T11 segmental arteriogram: Selective injection of the right T11 segmental artery demonstrates the vessel and its distal branches fill out well. There is no evidence of supply to arteriovenous fistula or spinal artery noted on this injection.
14. Left T5 segmental arteriogram: Selective injection of the left T5 segmental artery demonstrates the vessel and its distal branches fill out well. There is no evidence of supply to arteriovenous fistula or spinal artery noted on this injection.
15. Left T6 segmental arteriogram: Selective injection of the left T6 segmental artery demonstrates the vessel and its distal branches fill out well. There is no evidence of supply to arteriovenous fistula or spinal artery noted on this injection.
16. Left T7 segmental arteriogram: Selective injection of the left T7 segmental artery demonstrates the vessel and its distal branches fill out well. There is no evidence of supply to arteriovenous fistula or spinal artery noted on this injection.
17. Left T8 segmental arteriogram: Selective injection of the left T8 segmental artery demonstrates the vessel and its distal branches fill out well. There is no evidence of supply to arteriovenous fistula or spinal artery noted on this injection.
18. Left T9 segmental arteriogram: Selective injection of the left T9 segmental artery demonstrates the vessel and its distal branches fill out well. Supply to the anterior spinal artery is noted at the level of left T9.
19. Left T10 segmental arteriogram: Selective injection of the left T10 segmental artery demonstrates the vessel and its distal branches fill out well. There is no evidence of supply to arteriovenous fistula or spinal artery noted on this injection.
20. Left T11 segmental arteriogram: Selective injection of the left T11 segmental artery demonstrates the vessel and its distal branches fill out well. There is no evidence of supply to arteriovenous fistula or spinal artery noted on this injection.

IMPRESSION: Spinal arteriogram demonstrates a spinal dural arteriovenous fistula supplied by the right T7 segmental artery. Supply to the anterior spinal artery is noted at the level of left T9.

 

[Laureen Jandroep]

The most likely reason the provider billed 24 units for CPT 36215 is a misunderstanding of how to count units—possibly counting each injection or repeat access rather than each unique first-order vessel catheterized. The correct approach is to count each unique vessel accessed, which should yield a lower number (14–18) based on the operative report. You can explain that coding guidelines specify one unit per unique first-order vessel, not per injection or repeat access.