AMA Clinical Examples in Radiology - 2023 Issue 1 (Winter)
Bilateral Diagnostic Pulmonary Angiography and Mechanical Thrombectomy
Winter 2023 pages 10-11 CLINICAL EXAMPLE 2 Bilateral Diagnostic Pulmonary Angiography and Mechanical Thrombectomy CLINICAL HISTORY A 53-year-old male with recent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) pneumonia presents with sudden hypoxia and chest pain. Computed tomographic angiography (CTA) of the chest was performed revealing bilateral pulmonary emboli including a saddle pulmonary embolus and non-diagnostic evaluation of the segmental and subsegmental branches secondary to insufficient contrast present in these distal vessels at the time of imaging. Echocardiogram revealed septal dyskinesis with a dilated hypokinetic right ventricle. The patient had systemic hypotension and troponins were also elevated...
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Article Overview
This article is a radiology coding case example from Clinical Examples in Radiology. It discusses how a bilateral pulmonary embolism workup and mechanical thrombectomy case is documented and coded, along with related diagnostic angiography, catheter placement, ultrasound-guided access, moderate sedation, fluoroscopy reporting, and diagnosis coding considerations. It is intended for coders, radiology billers, and clinicians involved in interventional pulmonary embolism procedures.
Why This Topic Matters
Pulmonary embolism interventions often involve multiple procedure components and supporting documentation. This type of article helps readers understand the scope of services discussed in a complex interventional radiology case and the kinds of coding topics addressed.
Article Sections
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Clinical Example 2
Introduces the case presentation and the procedural scenario being analyzed for coding purposes.
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Clinical History
Summarizes the patient presentation, imaging findings, and clinical context leading to the intervention.
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Technique
Describes the procedural setup, access, imaging, catheter work, thrombectomy, and post-procedure documentation elements.
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Findings
Presents the imaging and hemodynamic findings associated with the procedure and outcome.
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Impression
Provides the overall procedural interpretation and post-procedure summary.
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How to Code
Explains the coding topics addressed in the case, including procedure reporting, diagnostic imaging, access guidance, sedation, fluoroscopy documentation, and diagnosis coding.
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Discussion
Reviews the broader coding and documentation issues relevant to the case and references professional coding guidance and payer considerations.
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Sources
Lists the reference materials and publication sources cited for the article.
What You Will Learn
- The overall structure of a complex interventional radiology coding example
- The types of documentation typically discussed for pulmonary angiography and thrombectomy cases
- How related procedural components are grouped in a case-based coding discussion
- The general categories of coding guidance referenced for diagnosis, imaging, sedation, and fluoroscopy reporting
Who Should Read This
- Interventional radiology coders
- Radiology billing staff
- Clinical documentation specialists
- Physicians and advanced practice providers involved in vascular interventions
- Health information management professionals
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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