AMA Clinical Examples in Radiology - 2007 Issue 1 (Winter)
Uterine Fibroid Embolization
Uterine Fibroid Embolization Reason for Exam Uterine fibroids with refractory heavy menstrual bleeding Impression Enlarged uterine fibroid with dominant right uterine artery supply Successful embolization utilizing transcatheter technique and PVA particles, as described below Procedure Uterine fibroid embolization Consent Informed consent was obtained. Techniques The patient was marked, prepped, draped, in standard fashion with continuous hemodynamic monitoring established. Moderate sedation was instituted with IV midazolam and fentanyl with additional doses given during the procedure as needed. Access was obtained through the right common femoral artery and a 5-French catheter was placed at the level of the ovarian artery takeoffs...
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Article Overview
This article covers uterine fibroid embolization from a coding perspective, focusing on the procedure workflow, radiology documentation, and the CPT guidance associated with reporting the service. It is relevant to radiology coders, billing staff, and clinicians who document or review uterine artery embolization cases. The discussion also places the procedure in context with older embolization reporting concepts, global surgery concepts, and moderate sedation references.
Why This Topic Matters
Correct reporting of uterine fibroid embolization depends on understanding the procedure as documented, the associated imaging and access work, and how CPT guidance frames the service. This article helps readers identify the broad coding framework and related references that may affect review of the case.
Article Sections
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Reason for Exam / Impression / Procedure
Introduces the clinical indication, overall impression, and the procedure being performed.
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Consent
Notes that informed consent was obtained before the procedure.
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Techniques
Summarizes the procedural workflow, vascular access, catheter placement, imaging, embolization steps, and post-procedure completion.
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Acronyms and Their Corresponding Terms
Defines abbreviations used in the report for imaging, medication, and embolization materials.
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Complications
States whether any complications occurred during the procedure.
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Technical Summary
Provides a concise summary of the catheterization and embolization work performed.
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Findings
Describes the angiographic findings before, during, and after treatment.
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Plan
Outlines the immediate post-procedure monitoring and supportive care plan.
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Fluoro Time
Lists the fluoroscopy time recorded for the procedure.
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Contrast
Lists the contrast agent and amount used during the study.
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How to Code
Identifies the primary CPT reporting guidance associated with this type of procedure.
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Discussion
Reviews broader CPT background for uterine fibroid embolization, including related embolization references and general coding context.
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Coding Tips
Provides general coding background related to global surgery concepts, embolization reporting, and sedation-related references.
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Endnotes
Lists source references and supporting citations.
What You Will Learn
- How uterine fibroid embolization is presented in a radiology report
- What general CPT coding guidance is associated with the procedure
- How the article frames related embolization reporting concepts
- What supporting documentation elements are highlighted in the case
- Which broader administrative and coding references are discussed
Who Should Read This
- Medical coders
- Radiology billing staff
- Revenue cycle professionals
- Interventional radiology clinicians
- Coding auditors
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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