New 2017 CPT Codes for Dialysis Entry Upkeep and Intervention

New 2017 CPT Codes for Dialysis Access Maintenance and Intervention
September 29, 2020 0 Comments

A number of new codes had been launched to be used to start with of 2017 that describe diagnostic and interventional procedures for hemodialysis entry. The beforehand used codes (36147, 36148, 36870, 75791, 35476, 75798, 35475, 75962) have been retired and may not be used. The brand new codes are extra bundled than the older codes and require data of up to date definitions for dialysis “vessels” as outlined for CPT coding for these providers. Usually, the brand new codes are easy, however there are some nuances that might be mentioned and illustrated with coding eventualities.

THE NEW CODES

⚫ 36901

Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, together with all direct puncture(s) and catheter placement(s), injection(s) of distinction, all obligatory imaging from the arterial anastomosis and adjoining artery by whole venous outflow together with the inferior or superior vena cava, fluoroscopic steering, radiologic supervision and interpretation and picture documentation and report;

⚫ 36902

with transluminal balloon angioplasty, peripheral dialysis phase, together with all imaging and radiologic supervision and interpretation essential to carry out the angioplasty

⚫ 36903

with transcatheter placement of intravascular stent(s), peripheral dialysis phase, together with all imaging and radiologic supervision and interpretation essential to carry out the stenting, and all angioplasty throughout the peripheral dialysis phase

⚫ 36904

Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any technique, together with all imaging and radiologic supervision and interpretation, diagnostic angiography, fluoroscopic steering, catheter placement(s), and intraprocedural pharmacologic thrombolytic injection(s);

⚫ 36905

with transluminal balloon angioplasty, peripheral dialysis phase, together with all imaging and radiologic supervision and interpretation essential to carry out the angioplasty

⚫ 36906

with transcatheter placement of intravascular stent(s), peripheral dialysis phase, together with all imaging and radiologic supervision and interpretation essential to carry out the stenting, and all angioplasty throughout the peripheral dialysis circuit

⚫ ➕ 36907

Transluminal balloon angioplasty, central dialysis phase, carried out by dialysis circuit, together with all imaging and radiologic supervision and interpretation required to carry out the angioplasty (listing individually along with code for main process)

⚫ ➕ 36908

Transcatheter placement of intravascular stent(s), central dialysis phase, carried out by dialysis circuit, together with all imaging radiologic supervision and interpretation required to carry out the stenting, and all angioplasty within the central dialysis phase (listing individually along with code for main process)

⚫ ➕ 36909

Dialysis circuit everlasting vascular embolization or occlusion (together with fundamental circuit or any accent veins), endovascular, together with all imaging and radiologic supervision and interpretation obligatory to finish the intervention (listing individually along with code for main process)

THE NEW DEFINITIONS

For coding functions, the next definitions apply to this set of codes.

Dialysis circuit: The segments of vessel/graft extending from the arterial anastomosis to the proper atrium. The perianastomotic phase, together with the artery instantly adjoining to the arterial anastomosis, the arterial anastomosis itself, and the brief phase of venous outflow instantly adjoining to the arterial anastomosis are included within the dialysis circuit. The dialysis circuit consists of two segments, the (1) peripheral dialysis phase and (2) central dialysis phase.

Peripheral dialysis phase: The portion of the dialysis circuit that begins on the arterial anastomosis and extends to the central dialysis phase. Within the higher extremity, the peripheral dialysis phase extends by the axillary vein (or by the complete cephalic vein within the case of cephalic venous outflow). Within the decrease extremity, the peripheral dialysis phase extends by the frequent femoral vein. The “perianastomotic” phase is outlined as a part of the peripheral dialysis phase. Any intervention within the perianastomotic area is due to this fact reported with the brand new codes and is not individually reported as an arterial intervention.

Central dialysis phase: Contains all draining veins central to the peripheral dialysis phase. Within the higher extremity, the central dialysis phase contains the veins central to the axillary and cephalic veins, together with the subclavian and innominate veins by the superior vena cava. Within the decrease extremity, the central dialysis phase contains the veins central to the frequent femoral vein, together with the exterior iliac and customary iliac veins by the inferior vena cava. Different named or unnamed veins could also be included on this phase. For example, giant collateral veins could develop within the neck to avoid a stenosis or occlusion of the subclavian vein, draining into the central vein by way of the jugular vein. On this case, the massive collateral veins and jugular vein are outlined as a part of the central dialysis phase.

GENERAL INSTRUCTIONS FOR THIS CODE SET

This code set is inclusive of most providers supplied. The codes are constructed on progressive hierarchies such {that a} single code is reported for all providers supplied in a phase of the dialysis entry. One base code (36901–36906) is reported, utilizing the code that describes the highest-intensity service supplied. These codes embody all punctures of and catheter manipulations from direct punctures of the dialysis circuit, all diagnostic imaging, all radiologic supervision and interpretation used to carry out the diagnostic examine and interventions, all street mapping, and all angiography, together with completion angiography. Closure of the puncture(s) by any technique, together with suture, is included in every code on this household.

36901 describes a diagnostic fistulagram carried out by way of direct puncture(s) of the dialysis circuit and contains imaging from the instant influx portion of the artery by the proper atrium. All punctures of the dialysis circuit and all catheterizations of the dialysis circuit are included in 36901. It’s not required that the complete circuit is imaged to report this code, however CPT specifies that each one obligatory imaging be carried out. It’s anticipated that typically, the complete circuit could be studied in line with nationwide tips, however it’s acknowledged that sometimes a whole diagnostic examine is just not wanted or indicated. 36902–36906 additionally embody the providers of 36901 when carried out, and 36901 is just not reported along with 36902–36906.

36902 describes balloon angioplasty of the peripheral dialysis phase carried out from direct punctures of the dialysis circuit. It’s reported as soon as whatever the variety of lesions handled, variety of balloons used, or kind of balloon(s) used (eg, plain balloon, high-pressure balloon, reducing balloon, drug-coated balloon [DCB]). Balloon angioplasty of the perianastomotic phase is reported utilizing 36902.

36903 describes stent placement within the peripheral dialysis phase carried out from direct punctures of the dialysis circuit. It’s reported as soon as whatever the variety of lesions handled and the quantity or kind of stent(s) used (eg, self-expanding, drug-eluting, lined). It additionally contains any balloon angioplasty completed within the peripheral dialysis phase, even when balloon angioplasty alone is carried out on some lesions and stenting alone is carried out on different lesions within the peripheral dialysis phase.

36904 describes a declot process of the dialysis circuit. This contains clot removing by any means from the peripheral and/or central dialysis segments and is reported as soon as even when thrombus is handled in each the peripheral and central dialysis segments. This code additionally contains all direct punctures of the dialysis circuit and all catheterizations carried out from direct punctures of the dialysis circuit. A diagnostic fistulagram is included in 36904; code 36901 is just not individually reported.

36905 contains the providers described by 36904 plus any balloon angioplasty within the peripheral dialysis phase carried out by way of direct puncture(s) of the dialysis circuit. Just like code 36902, all angioplasty carried out within the peripheral dialysis phase is included in 36905, and the code is reported as soon as whatever the variety of lesions handled with balloon angioplasty.

36906 contains the providers described by 36904 and 36905, plus any stent placement carried out within the peripheral dialysis phase when positioned by way of direct puncture(s) of the dialysis circuit. This code is reported as soon as whatever the variety of stents positioned, variety of lesions stented or handled with balloon angioplasty within the peripheral dialysis phase, or the kind of stent(s) or balloon(s) used.

There are three add-on codes which may be moreover reported (36907, 36908, 36909). These codes are reported with 36901–36906. Codes 36907 and 36908 may be reported with surgical codes 36818–36833 when central dialysis phase interventions are carried out on the time of open surgical procedures for the dialysis circuit.

36907 describes angioplasty within the central venous phase when carried out by way of a direct puncture of the dialysis circuit and contains all angioplasty carried out within the central venous phase. Code 36907 is reported as soon as, even when a number of stenoses are handled and a number of balloons are used and contains all forms of angioplasty (eg, plain balloon angioplasty, reducing balloon, DCB).

36908 describes stenting within the central venous phase when carried out from a direct puncture of the dialysis circuit. It contains all angioplasty and completed within the central venous phase along with all stenting and is reported as soon as whatever the variety of lesions handled and quantity or kind of stents/balloons used.

36909 describes embolization of the circuit or aspect branches and is reported as soon as whatever the variety of vessels handled or the quantity/kind of embolic supplies used. Code 36909 doesn’t specify that the entry have to be by direct puncture of the dialysis circuit and is used whatever the method used. Code 37240 is just not reported for embolization within the dialysis circuit, even when the vessels are approached from an entry apart from direct puncture of the dialysis circuit. If the method is from direct puncture of the dialysis circuit, a base code (36901–36906) is reported with 36909, however no extra catheterization codes are reported, even when a number of aspect branches are chosen to finish the embolization.

SERVICES NOT INCLUDED IN 36901–36909

Though the brand new codes embody many of the providers carried out for dialysis entry upkeep, there are parts which may be individually reported when carried out. These embody:

Ultrasound steering for puncture of the dialysis entry (76937) could also be individually reported when used for a failing or immature arteriovenous fistula (AVF). The required parts for reporting 76937 have to be documented (evaluation of vessel patency, use of ultrasound [US] to visualise needle entry into the vessel, and archival of a picture to the affected person’s everlasting report) when this code is reported. CPT specifies that US steering is just not usually carried out and likewise specifies that it’s used for a failing or immature AVF, however fails to say use for arteriovenous graft (AVG) punctures. It’s not but clear whether or not there might be limits to cost for this element, however clear documentation of the indication to be used of US steering would appear to be prudent.

Catheterizations carried out from vessel punctures apart from direct puncture of the dialysis circuit could also be individually reported. Widespread femoral vein or artery, inner jugular vein, and brachial artery punctures are examples of other entry websites which may be used to entry the dialysis circuit. CPT specifies that these approaches are usually not used routinely and that the medical report should doc the scientific indication for utilizing an method apart from direct puncture of the dialysis circuit (CPT Assistant, March 2017). For instance, catheterization of a forearm AVF from a standard femoral venous puncture could be individually reported with 36012.

As a result of codes 36901–36906 embody the work of accessing the dialysis circuit, if the providers are carried out with out puncturing the dialysis circuit (ie, from a separate entry such because the femoral vein), the dialysis code could be reported with a -52 (diminished service) modifier, indicating that direct puncture of the AVF was not carried out. For example, if a diagnostic fistulagram had been carried out for a forearm AVF from a femoral vein puncture, 36901-52 could be reported with 36012. If punctures of each the femoral vein and the dialysis circuit had been required to carry out the diagnostic examine, 36901 plus 36012 could be reported (with out modifier -52).

It’s not but clear if there might be cost points for these practices that routinely use alternate entry websites, since CPT and CPT Assistant have been clear that different entry websites are usually not usually indicated. Clear documentation of rationale for alternate puncture web site(s) ought to at all times be given.

Diagnostic angiography of the influx artery could also be individually reported when carried out to evaluate a suspected influx drawback. Analysis of the arterial phase instantly above the perianastomotic phase/arterial anastomosis is included in 36901–36906 and wouldn’t be individually reported. Nonetheless, 75710-59 could also be individually reported when an extremity arteriogram is required (eg, suspected influx abnormality, steal syndrome).

Selective catheterization of the influx artery could also be individually reported when required when diagnostic arteriography is carried out to evaluate a suspected drawback within the influx vessel. Within the arm, this may be reported with 36245-59. If the catheter is superior into the aorta (eg, to completely assess a stenosis on the origin of the arch department), 36200 is just not moreover reported. Further selective catheterization of the influx artery is NOT reported when the catheter is superior by the arterial anastomosis to finish the diagnostic fistulagram (36901) or to carry out intervention of the perianastomotic phase or the peripheral dialysis phase. It’s understood that to check and deal with the arterial anastomosis, the catheter/wire should at all times be superior into the influx artery within the case of intervention and is typically superior into the influx artery to finish the diagnostic examine. Due to this fact, advancing the catheter by the arterial anastomosis is included in codes 36901–36906 for all functions of performing the examine, the interventions, and follow-up imaging after intervention.

IVUS (37252, 37253) could also be reported individually if used for diagnostic and/or therapeutic steering.

Venous stenting (nondialysis vessel, 37238, 37239) could also be reported for interventions within the central dialysis phase, however solely when approached from punctures apart from direct puncture of the dialysis circuit. When stenting of the central dialysis phase is carried out from any puncture apart from direct puncture of the dialysis circuit, 37238/37239 are reported. On this occasion, the venous stenting codes are reported per anatomic vessel relatively than the outlined central dialysis phase “vessel.” As a result of the CPT descriptors for venous angioplasty (37248, 37249) specify that these codes are to not be reported for angioplasty within the dialysis circuit, they shouldn’t be reported for central venous angioplasty in a dialysis circuit, even when carried out from an method apart from direct puncture of the dialysis circuit. As well as, the nondialysis venous and/or arterial angioplasty or stenting codes shouldn’t be reported for interventions within the peripheral dialysis phase, even when approached from a puncture apart from direct puncture of the dialysis circuit.

CODING SCENARIOS

Case 1

A affected person is seen for analysis of a poorly creating AVF within the left forearm. Puncture of the AVF is carried out, and a brief catheter is superior retrograde into the vein to close the arterial anastomosis. Imaging is obtained from the arterial anastomosis by the superior vena cava (SVC).

Coding: 36901. This identical code could be used if the imaging had been completed by a needle as an alternative of a catheter. All maneuvers used to allow visualization of the complete dialysis circuit are included in 36901.

Case 2

A affected person is evaluated for poorly creating AVF within the left forearm. Antegrade and retrograde punctures of the dialysis circuit are carried out, with catheters superior retrograde by the arterial anastomosis and antegrade into the SVC to carry out full imaging of the complete dialysis circuit.

Coding: 36901. All catheterizations and punctures of the dialysis circuit are included in 36901. Though an extra puncture was carried out and extra intensive selective catheterization was carried out as in contrast with case 1, the coding is similar. Development of the catheter by the arterial anastomosis for completion of the diagnostic examine is included in 36901. Imaging of the influx artery instantly proximal to the arterial anastomosis is included in 36901.

Case 3

A affected person is evaluated for poorly creating AVF within the left forearm. As in case 2, a diagnostic examine is carried out. A stenosis of the arterial anastomosis is recognized and handled with balloon angioplasty, and the catheter is superior retrograde past the arterial anastomosis for last imaging to doc profitable remedy.

Coding: 36902. The diagnostic examine is included in 36902 and isn’t individually reported. The perianastomotic angioplasty is reported utilizing the particular code for peripheral dialysis phase angioplasty, not a much less particular code for arterial angioplasty.

Case 4

A affected person is seen for failing dialysis entry with extended bleeding and poor flows. The AVF is punctured in a retrograde course and diagnostic examine is carried out, figuring out stenosis on the arterial anastomosis in addition to a focal stenosis within the outflow cephalic vein within the higher arm. These stenoses are handled with balloon angioplasty, requiring a second puncture in an antegrade course to deal with the cephalic vein stenosis. DCBs are used for every lesion, requiring two separate balloons.

Coding: 36902. This code contains the diagnostic examine in addition to all angioplasty carried out within the peripheral dialysis phase, so it’s reported solely as soon as. All punctures of the dialysis circuit are included in 36902 and are usually not individually reported.

Case 5

A affected person is seen for failing dialysis entry. Retrograde puncture of the entry is carried out, with development of the catheter tip by the arterial anastomosis. A stenosis of the arterial anastomosis is discovered, in addition to a recurrent stenosis in a beforehand handled lesion within the cephalic arch on the shoulder. The arterial anastomosis is handled utilizing balloon angioplasty, and the cephalic arch stenosis is handled utilizing balloon angioplasty carried out by a second puncture (antegrade), adopted by stent placement as a consequence of lack of ability to completely open the lesion with balloon angioplasty.

Coding: 36903. All angioplasty and stenting carried out within the peripheral dialysis phase by direct puncture(s) of the dialysis circuit are included in 36903. Though separate lesions had been handled with balloon angioplasty and stenting, solely the highest-intensity code (stent placement) is reported. The diagnostic examine is included in 36903, in addition to all catheterizations.

Case 6

A affected person presents with no circulate in his AVF. The dialysis circuit is punctured utilizing US steering (with documentation of the required parts), and a fistulagram demonstrates thrombosis of the vein extending into the subclavian vein. A second puncture is carried out, additionally utilizing US steering, and mechanical thrombectomy is used to clear the thrombus from the circuit. Tissue plasminogen activator (tPA) is infused into the thrombus as properly. The arterial plug is eliminated through the use of {a partially} inflated angioplasty catheter to tug the plug into the fistula. As soon as circulate is restored, a stenosis is recognized within the outflow cephalic vein, which is opened with a lined stent.

Coding: 36906, 76937. Codes 36904, 36905, and 36906 embody removing of thrombus from the dialysis circuit utilizing any means and embody removing from each the peripheral and/or central dialysis segments. These codes are reported as soon as, even when thrombus is faraway from each the peripheral and central dialysis segments, as was required on this case. As a result of stenting was additionally carried out, the highest-intensity code together with all providers is 36906. Code 76937 is reported to be used of US steering and is reported as soon as though it was used for 2 separate punctures into the dialysis circuit.

Case 7

A affected person presents with no circulate of their AVG. Puncture of the dialysis circuit is carried out underneath US steering (with documentation of the required parts), and tPA is fastidiously laced into the vein and is allowed to dwell for 1 hour. The affected person is then taken to the interventional suite, and the arm prepped and draped. A second puncture is made into the graft, and fistulagraphy is carried out, which demonstrates thrombosis of the vein extending into the basilic vein on the mid-arm degree. The thrombus is eliminated utilizing mechanical thrombectomy, and a Fogarty catheter is used to take away the arterial plug. A stenosis of the subclavian vein is handled utilizing balloon angioplasty, and a stenosis of the venous anastomosis is handled utilizing balloon angioplasty.

Coding: 36905, 36907, 76937. Code 36905 contains declot of the fistula (and contains each the tPA lyse-and-wait in addition to the mechanical thrombectomy and Fogarty balloon maneuvers), plus the angioplasty of the venous anastomosis. If the Fogarty balloon had been the one balloon wanted within the peripheral dialysis phase to take away the arterial plug, 36904 could be reported. Use of a balloon to take away the arterial plug is included in 36904. Balloon angioplasty of the central dialysis phase (subclavian vein) is reported utilizing the add-on code 36907.

Case 8

Fistulagraphy is carried out by way of a retrograde puncture of the dialysis circuit, which demonstrates recurrent stenosis inside beforehand positioned stents within the subclavian and innominate veins. A second puncture is carried out into the dialysis circuit in an antegrade course, and balloon angioplasty is carried out in each areas of stenosis. Closing imaging demonstrates opening of the stenosis with restoration of circulate.

Coding: 36901, 36907. Code 36907 is an add-on code and have to be reported with one other code. It contains angioplasty of all stenosis handled within the central dialysis phase. Code 36901 is reported as the bottom code, as a result of it represents the highest-intensity service carried out within the peripheral dialysis circuit (diagnostic examine). All catheterizations are included in codes 36901 and 36907.

Case 9

Fistulagraphy is carried out by way of a retrograde puncture of the dialysis circuit, which demonstrates stenosis on the arterial anastomosis. As well as, stenoses are recognized within the cephalic arch on the shoulder and within the innominate vein. The arterial anastomotic stenosis is handled with balloon angioplasty, the cephalic arch stenosis is handled with stenting after ballooning solely partially opens the lesion, and the innominate vein stenosis is handled with balloon angioplasty.

Coding: 36903, 36907. As a result of the cephalic arch lesion and the arterial anastomosis lesion are each within the peripheral dialysis phase, a single code is used to report these two interventions, deciding on 36903 for the highest-intensity service (stent) carried out on this phase. The add-on code 36907 is reported for the angioplasty carried out within the central dialysis phase.

Case 10

A affected person is referred for brand new AVF that’s sluggish to mature. Fistulagraphy is carried out utilizing antegrade puncture of the fistula. The fistula is manually occluded to drive distinction retrograde and allow visualization of the proximal parts of the AVF, after which outflow imaging is carried out by the SVC. The diagnostic examine reveals that the veins are patent, however two giant aspect branches are discovered which can be siphoning circulate from the cephalic outflow vein. These veins are selectively catheterized, and angiography is carried out in every of the branches to substantiate anatomy and dimension. Every is then closed with a single coil.

Coding: 36901, 36909. Code 36901 is the bottom code reported and describes the fistulagram. Code 36909 is reported as soon as for the embolization. These codes embody all catheterizations carried out from direct puncture of the fistula, in addition to all diagnostic angiography carried out. There isn’t a extra coding for department venography or department selective catheterization. Observe-up angiography is included in 36909.

Case 11

A affected person presents with failing AVF, together with elevated venous pressures, issue puncturing fistula, and extended bleeding after dialysis. The arm is swollen and bruised, so it’s elected to method the fistula from a distant puncture, and a proper frequent femoral vein method is chosen. The femoral vein is punctured, and a catheter is maneuvered into the left subclavian vein after which selectively maneuvered into the fistula within the left forearm. Diagnostic fistulagraphy is carried out, demonstrating an arterial anastomotic stenosis plus a stenosis within the subclavian vein. The arterial anastomotic stenosis is handled with balloon angioplasty, and the subclavian vein stenosis is handled utilizing a stent, all carried out from the proper femoral venous puncture.

Coding: 36902-52, 37238 (placement of venous stent), 36012 (second order selective venous catheterization). The -52 modifier for diminished providers is appended to 36902 to suggest that no puncture of the dialysis circuit was carried out. Code 37238 is used to report the central dialysis phase stent placement, which was carried out by a puncture apart from direct puncture of the dialysis circuit.

Case 12

On day 1, a affected person presents with suspicion of stenosis inside their dialysis entry. Fistulagraphy is carried out by way of direct puncture of the fistula, documenting stenosis within the cephalic vein within the arm, in addition to three separate central phase stenoses within the subclavian vein, the innominate vein, and the SVC. The working doctor is unsure whether or not intervention can save this entry, so the affected person is referred to a surgeon. The surgeon determines that continued efforts to take care of this entry needs to be made whereas choices for a brand new entry are explored. On day 2, the affected person returns for remedy of the entire stenoses. Interventions are carried out from a femoral venous method, however no cause for utilizing an method apart from direct puncture of the dialysis circuit is documented. No extra diagnostic research are carried out. Balloon angioplasty is used to deal with all 4 areas of stenosis.

Coding for day 1: 36901; coding for day 2: 36902-52, 36907, 36012. On the primary day, diagnostic fistulagraphy is carried out and is reported with 36901. On the second day, the balloon angioplasty carried out within the peripheral dialysis phase (cephalic vein) is reported with 36902 utilizing a -52 modifier to suggest a diminished service as a result of the dialysis circuit was not punctured. As a result of 37248 and 37249 can’t be reported for angioplasty carried out within the dialysis circuit, 36907 is the right code and describes remedy of all three stenoses of the central phase. As a result of the -52 modifier used with 36902 accounts for the shortage of direct puncture of the dialysis circuit, -52 will not be wanted with 36907. Code 36012 is reported for the selective catheterization carried out from the femoral method. If the service audits this case, 36012 could also be denied as a result of no cause was documented for the necessity for an method apart from direct puncture of the dialysis circuit.

Case 13

The identical affected person as in case 12 returns on day 2 for remedy, which is once more carried out from a femoral puncture, however as an alternative all 4 of the lesions are handled with stenting.

Coding for day 2: 36903-52, 37238, 37239, 37239, 36012. Code 36903 is reported for stenting of the peripheral phase stenosis (cephalic vein), with a -52 modifier to indicate that direct puncture of the dialysis circuit was not carried out. The stenting within the central dialysis phase could also be reported utilizing the nondialysis venous stenting codes as a result of this was approached from the femoral vein relatively than direct puncture of the dialysis circuit. On this case, three separate anatomic veins had been handled (subclavian, innominate, and SVC) with stents. 37238 is reported as soon as for the preliminary vein handled, and 37239 is reported twice for the 2 extra veins handled. Code 36012 is reported for the catheterization of the veins from the femoral puncture. Though a number of veins had been catheterized, solely probably the most selective one is reported, as a result of the catheter handed by all the opposite areas of stenosis to succeed in the cephalic vein, with no extra department chosen.

Case 14

The affected person presents for brand new proper forearm AVF that isn’t maturing. Fistulagraphy is carried out utilizing a retrograde puncture carried out underneath US steering (with required parts documented). The tip of the catheter is superior by the arterial anastomosis to permit visualization of the complete fistula. No stenosis is discovered.

Coding: 36901, 76937. Whether it is suspected that the failure to mature is because of an influx stenosis, extra diagnostic work could also be required. On this case, the catheter is selectively maneuvered to the origin of the innominate artery and proper arm arteriography is carried out. This demonstrates a stenosis in the proper subclavian artery, which is handled with balloon angioplasty.

Further coding: 37246-59, 36215-59, 75710-59. On this case, as a result of an entire arteriogram was carried out for particular suspicion of an influx stenosis, and since the catheter was superior retrograde to the extra proximal artery, 75710 and 36215 are reported. A primary-order selective catheterization is used, as a result of because the catheter is maneuvered retrograde by the vessel, there isn’t any vessel branching requiring extra selectivity as could be encountered when traversing this identical vessel in an antegrade course. If the catheter was superior into the aorta, 36215 continues to be the right code to report (36200 is included within the work of 36215 and wouldn’t be individually reported). Code 37246 is used to report balloon angioplasty of the subclavian artery, as a result of the subclavian artery is a separate vessel and never a part of the dialysis circuit. The -59 modifier is used with all of those codes to indicate that they symbolize distinct procedural service, separate from the diagnostic examine or any intervention carried out within the dialysis circuit itself.

Case 15

The affected person presents with a left arm AVF that’s failing to mature. Diagnostic fistulagraphy is carried out by way of retrograde puncture of the AVF, utilizing US steering for the puncture and documenting all required parts. No stenosis is recognized, so intravascular ultrasound (IVUS) is used to acquire additional diagnostic info. A second (antegrade) puncture is carried out, and diagnostic IVUS is carried out by the dialysis circuit within the peripheral phase, confirming no structural abnormality inflicting failure to mature.

Coding: 36901, 37252. On this case, the entire punctures are included in 36901, though a separate puncture was carried out particularly for the IVUS. On this case, as a result of IVUS was carried out solely within the peripheral dialysis phase, 37252 is reported to incorporate the complete dialysis “vessel” studied, relatively than reporting IVUS per anatomic vessel.

Case 16

Throughout surgical creation of a left arm direct AVF, fistulagraphy is carried out, and a stenosis is discovered within the outflow cephalic vein within the higher arm. That is handled with balloon angioplasty, along with the deliberate revision of the arterial anastomosis.

Coding: 36821. All the peripheral dialysis phase is taken into account the identical surgical discipline because the arteriovenous anastomosis in surgical instances, so diagnostic examine and any endovascular therapies carried out on this territory in the course of the surgical process are usually not individually reported. Though the stenosis within the cephalic outflow vein is distant from the surgical incision, it isn’t outlined as a central dialysis phase vein and is thus not individually reported.

The central dialysis phase is just not thought-about to be in the identical surgical discipline because the arteriovenous anastomosis, and if stenosis was recognized and handled within the central dialysis phase throughout this identical surgical process, it may very well be reported utilizing the add-on codes 36907 for balloon angioplasty or 36908 for stent placement. These two codes could also be added on to the surgical codes 36818–36833 and don’t require a code from the 36901–36906 collection as a base code. When utilized in a surgical setting, the principles to be used are the identical as when used with the percutaneous codes 36901–36906. Solely certainly one of these codes could be reported, deciding on the one inclusive of the best depth service carried out, and that code is reported as soon as for all interventions carried out within the central dialysis phase. No extra catheterization code could be reported, as that’s included in 36907 and 36908 when the entry is direct into the dialysis circuit (whether or not percutaneous or open).

CONTACT US

When you have any questions or subjects you desire to Dr. Krol to deal with in a future column, please contact us at [email protected]

Katharine L. Krol, MD, FSIR, FACR
Retired Interventional Radiologist
Disclosures: None.

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