Abdominal interventional radiology coding is an area that poses risks for many coders, compliance professionals, and facilities across the nation. Coders face strong undercurrents of confusion in a sea of complexities, and accurate coding may sink to the depths of misunderstanding without fortified education in this area. In fact, the topics in this area are so diverse and intricate that our experts have identified it as an area worthy of review. Within the realm of medical imaging and abdominal coding, the technique of splenoportography unveils a critical avenue for healthcare professionals to gain profound insights into the vascular dynamics of the human body. Here, we will review the nuances of this service to reinforce knowledge for an accurate understanding.
This intricate procedure involves the introduction of a radiopaque substance into the spleen, a crucial organ nestled beneath the ribcage. What is the primary objective of performing this service? To achieve comprehensive radiographic visualization not only of the splenic vessels but also the main portal veins that intricately weave through the portal circulation system.
Contrast is injected into either the portal system, or more selectively into the splenic vein, to assess blood flow to the spleen. This is performed when other more less invasive imaging modalities are unable to elucidate findings for potential symptoms, or when interventional vascular surgery is being planned and performed, such as embolizations for hemorrhage, treatment of AVMs or tumors, thrombectomy of the vessels that supply the spleen. This can also be performed for pre-surgical planning for chemo or radio embolizations or for liver transplants.
The overarching purpose of the service is to evaluate the status of the splenic or portal venous system when they aren’t able to be seen/studied on other exams such as the venous phase of a celiac or splenic angiogram. Often, the most common objective for doing this study is to assess for thrombosis of the splenic vein or portal vein.
So how does this service work and where precisely is it performed?
1. Patient Positioning and Marker Placement for X-Ray and Scout Film: The patient is carefully positioned, raising the left arm above the head – a crucial step that aids in optimal imaging. To ensure accuracy, a lead marker is strategically placed on the skin, approximately one and one-half inches below the xyphoid in the abdominal midline. This marker serves as a guiding star, allowing the centering of the radiographic tube and facilitating the precise placement of the percutaneous needle.
2. The Scout Film and Evaluation: Before proceeding, a scout film is obtained, a preliminary snapshot that sheds light on the lower lung field while also enabling the assessment of spleen size and position. This visual aid equips healthcare professionals with vital information that guides subsequent steps.
3. Preparation and Needle Insertion: Prepping and draping the left chest and abdomen mark the transition to the next phase. The ninth intercostal space becomes the focal point for needle insertion – the posterior axillary line for smaller spleens and the mid-axillary line for larger ones. An 18-gauge Teflon sleeve needle (for adults) or a 20-gauge needle (for children) is the instrument of choice. Carefully and horizontally inserted, it is advanced under fluoroscopy, at an angle of 15-20 degrees cephalad. The aim? Positioning the needle tip at the hilum of the spleen or above.
4. Confirmation and Connection: As the needle penetrates the splenic substance, a telltale sign emerges – a steady drip of blood. This signals progress and aligns with the intended target. Once positioned, the needle is connected using venotubing to a three-way stopcock, accompanied by a manometer and a syringe containing saline. This interconnected setup serves as a conduit for accurate measurements and controlled procedures.
5. Pressure Measurements and Contrast Injection: Moving forward, pressure measurements take center stage, providing professionals with a comprehensive understanding of the intrasplenic dynamics. On three separate readings, pressures are meticulously obtained, adding a layer of detail to the diagnostic endeavor. Following this, the needle is coupled with a syringe containing vascoray – a blend of meglumine iothalamate and sodium iothalamate, essential for contrast enhancement. A preliminary test injection of 5 cc of the contrast media is administered.
6. Contrast Medium Response: The moment of truth arrives as professionals observe the contrast medium’s interaction with the spleen. A properly placed needle manifests as a puddling of contrast medium within the splenic pulp, followed by the opacification of venous structures. This visual confirmation solidifies the accuracy of our placement.
7. Controlled Contrast Injection: With the needle’s position now validated, a controlled injection ensues. A manually administered infusion of 30 cc of contrast occurs over a ten-second span. The initial exposure of the radiographic film begins a mere two seconds after the commencement of injection.
In a normal splenoportogram, only the splenic and portal veins are opacified and the splenic pulp pressure is usually less than 20 mm. The blood flow is hepatopetal and none of the tributaries of the splenic or portal veins are visualized. The arborization of the intrahepatic branches of the portal vein are straight and orderly. The following codes encompass and detail these services:
These are not all the essential coding tips and rationale for basic interventional radiology knowledge and abdominal coding. As service volumes rebound and every dollar of reimbursement counts more than ever, it’s imperative to make sure your CPT® coding is correct and compliant. Master more IR coding topics and break down the complexity with our expert-infused 2023 Abdominal Interventional Radiology Coding, live on Wednesday, September 13, 2023. This webcast is an essential training tool for both audio and visual learners.
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