New Stent Codes for Dialysis Access Work

How to use the revised codes that debuted on January 1 of this year.

By Katharine L. Krol, MD, FSIR, FACR
 

The four new vascular stent codes that became effective on January 1, 2014 are pertinent to endovascular procedures for arteriovenous (AV) dialysis access maintenance:

  • 37236: Arterial stent placement, initial vessel
  • +37237: Arterial stent placement, each additional vessel
  • 37238: Venous stent placement, initial vessel
  • +37239: Venous stent placement, each additional vessel

These new codes differ from the old codes in that they include not only the surgical work of stent placement but also the radiological supervision and interpretation (RS&I) work that was previously separately reported, as well as any angioplasty performed in the same vessel. This is true even if angioplasty is performed in a different segment or separate lesion and that segment or lesion is treated with angioplasty alone. The old stent codes included angioplasty of the same lesion when performed as part of the stent, but other angioplasty of separate lesions in the same vessel could be reported separately. The new codes do not include catheterization/ access of the vessel and do not include diagnostic angiography if performed.

For purposes of reporting procedures related to hemodialysis vascular access vessels, there are two coding definitions that can make it tricky when trying to determine the correct codes to use. The first is the nonanatomic definition of vessels that must be recognized, and the second is deciding whether to report the work performed in the AV dialysis vessel as arterial or venous.

NONANATOMIC DEFINITION OF VESSELS

The definition of “vessel” as it relates to AV dialysis endovascular coding has not changed with the introduction of the new stent codes and remains nonanatomic with three specifically defined vessels. Interventions may only be reported once per vessel, regardless of the number of lesions treated within each of these defined segments. The definitions used for determining the treated vessel are:

  1. The inflow arterial vessel includes the artery feeding the AV access up to, but not including, the perianastomotic segment of the vessel.

  2. The AV access vessel includes the segment of vessel and/or graft from the perianastomotic segment involving the arterial or AV anastomosis through the axillary vein. The cephalic vein, through its junction with the subclavian vein, is considered part of this AV access vessel.

  3. The outflow venous vessel includes the veins beyond the axillary and cephalic veins (eg, subclavian vein, innominate vein, and superior vena cava).

DETERMINATION OF ARTERIAL VERSUS VENOUS INTERVENTION CODE FOR THE AV ACCESS VESSEL

For purposes of coding, any and all angioplasty and stenting in the outflow vessel (from the arterial perianastomotic segment through the axillary/cephalic vein) is reported as a single intervention. The AV access vessel is considered a vein, and therefore venous codes for angioplasty and stenting would most commonly be used to report AV dialysis access interventions. There is an exception, however. The arterial perianastomotic segment is defined as arterial for purposes of coding interventions. If treatment of a stenosis in the arterial perianastomotic segment is performed, an arterial code can be used to describe that intervention. If the perianastomotic area is treated, the entire AV access vessel is then regarded as arterial for reporting purposes. Note that determination of treatment of the perianastomotic segment is defined by pathology in this segment, not simply by extension of the balloon or stent to this segment. For instance, a stenosis that is 3 cm above the anastomosis could be treated with a balloon that is extended to the anastomosis itself, but the angioplasty would be reported as a venous angioplasty since the definition is based on the location of the pathology.

CODING SCENARIOS

For purposes of discussion, only the codes for the intervention(s) performed are included in the following examples. Vessel access codes and diagnostic angiography codes would likely be applicable in addition to the codes listed below, but that documentation was omitted to allow focus on the discussion of the interventional codes.

Patient 1: Angioplasty of the Arterial Anastomosis
Coding: 35475/76942 (brachiocephalic artery angioplasty/RS&I arterial angioplasty)

Patient 2: Stent Placement at the Arterial Anastomosis
Coding: 37236 (arterial stent, initial vessel)

Patient 3: Performed Angioplasty of Arterial Anastomosis Is Unsuccessful in Sufficiently Opening Vessel, So Stent Is Placed
Coding: 37236 (arterial stent, initial vessel)
Note that even though all the work of angioplasty was performed with the intent that angioplasty would be the primary treatment, all the work of angioplasty is included in the work of 37236 and no additional angioplasty codes are reported.

Patient 4: Angioplasty of Arterial Anastomotic Lesion and Stenting of Brachial Vein in Upper Arm
Coding: 37236 (arterial stent, initial vessel). Because all therapies provided in the AV access vessel are reported with a single code, the highest level of intervention should be chosen. Stenting is considered more complex than angioplasty alone, so a stent code would be used to describe both the stenting and the angioplasty. Because the therapy at the arterial perianastomotic segment defines the AV access vessel as arterial for this encounter, an arterial code is used for the entire vessel.

Patient 5: Stent Placement at Arterial Anastomosis and Stenting of Brachial Vein in Upper Arm
Coding: 37236 (arterial stent, initial vessel). Regardless of the number of lesions treated or stents placed, a single intervention may be reported for all of the interventions performed in the entire AV access vessel. Since the perianastomotic segment was treated, the entire AV access vessel is considered arterial for coding purposes for this session.

Patient 6: Angioplasty Followed by Stenting of Arterial Anastomosis and Stenting of Brachial Vein in Upper Arm
Coding: 37236 (arterial stent, initial vessel). Regardless of the number of lesions treated or stents placed, a single intervention may be reported for all of the interventions performed in the entire AV access vessel. Since the perianastomotic segment was treated, the entire AV access vessel is considered arterial for coding purposes for this session.

Patient 7: Stent Placement in Brachial Vein
Coding:37238 (venous stent, initial vessel)

Patient 8: Angioplasty of Brachial Vein and Stent Placement in Subclavian Vein
Coding: 35476/75978 (venous angioplasty of the AV access vessel)
37238 (venous stent in the outflow vein)

Patient 9: Stent Placement at Arterial Perianastomotic Segment and Stent Placement in Subclavian Vein
Coding: 37236 (arterial stent placement for the AV access vessel [arterial perianastomotic segment])
37238 (venous stent placement for the outflow venous vessel [subclavian vein]). Note, there is an error in CPT 2014 that instructs users to report 37239 for treatment of a central venous stenosis if the arterial anastomosis has also been treated. However, CPT 2014 also states that 37239 may only be reported with 37236. This will be corrected in CPT 2015. The correct reporting is: 37236/37238.

Patient 10: Stent Placement in Brachial Vein and Stent Placement in Subclavian Vein
Coding: 37238 (venous stent placement for the brachial vein)
37239 (each additional venous stent placement for the subclavian vein).

Patient 11: Stent Placement in Subclavian Vein and Stent Placement in SVC
Coding: 37238 (venous stent placement, initial vessel). One intervention is reported for all therapy performed in the outflow venous vessel.

Patient 12: Stent Placement for a Stenosis 3 cm Distal to Arterial Anastomosis, Covered Stent Placement at Venous Anastomosis of AV Graft, and Stent Placement in Axillary Vein
Coding: 37238 (venous stent placement). This is coded once for the entire AV access vessel, regardless of the number of lesions treated, number of stents placed, and whether the stents are covered or bare metal.

Patient 13: Balloon Angioplasty of Long Segment of Stenosis of Cephalic Arch Outflow of an AVF, Requiring Stent Placement Extending Just Into Subclavian Vein
Coding: 37238 (venous stent placement). In this case, a single stent is placed, and even though it extends into the subclavian vein, which is defined as a separate vein from the cephalic vein for dialysis access maintenance, the venous stent code is reported only once because it is treating a single lesion.

Katharine L. Krol, MD, FSIR, FACR, is an interventional radiologist and has recently retired from active clinical practice. She has disclosed that she has no financial interests that pertain to this topic. Dr. Krol may be reached at (317) 595-9413.

 

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