New 2017 CPT Codes for Dialysis Access Maintenance and Intervention

A review of the new codes, new definitions, general instructions for the code set, and nuances of the new codes as illustrated by coding scenarios.

By Katharine L. Krol, MD, FSIR, FACR
 

Several new codes were introduced for use in the beginning of 2017 that describe diagnostic and interventional procedures for hemodialysis access. The previously used codes (36147, 36148, 36870, 75791, 35476, 75798, 35475, 75962) have been retired and can no longer be used. The new codes are more bundled than the older codes and require knowledge of updated definitions for dialysis “vessels” as defined for CPT coding for these services. In general, the new codes are straightforward, but there are some nuances that will be discussed and illustrated with coding scenarios.

THE NEW CODES

⚫ 36901

Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiologic supervision and interpretation and image documentation and report;

⚫ 36902

with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiologic supervision and interpretation necessary to perform the angioplasty

⚫ 36903

with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiologic supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis segment

⚫ 36904

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

⚫ 36905

with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiologic supervision and interpretation necessary to perform the angioplasty

⚫ 36906

with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiologic supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis circuit

⚫ ➕ 36907

Transluminal balloon angioplasty, central dialysis segment, performed through dialysis circuit, including all imaging and radiologic supervision and interpretation required to perform the angioplasty (list separately in addition to code for primary procedure)

⚫ ➕ 36908

Transcatheter placement of intravascular stent(s), central dialysis segment, performed through dialysis circuit, including all imaging radiologic supervision and interpretation required to perform the stenting, and all angioplasty in the central dialysis segment (list separately in addition to code for primary procedure)

⚫ ➕ 36909

Dialysis circuit permanent vascular embolization or occlusion (including main circuit or any accessory veins), endovascular, including all imaging and radiologic supervision and interpretation necessary to complete the intervention (list separately in addition to code for primary procedure)

THE NEW DEFINITIONS

For coding purposes, the following definitions apply to this set of codes.

Dialysis circuit: The segments of vessel/graft extending from the arterial anastomosis to the right atrium. The perianastomotic segment, including the artery immediately adjacent to the arterial anastomosis, the arterial anastomosis itself, and the short segment of venous outflow immediately adjacent to the arterial anastomosis are included in the dialysis circuit. The dialysis circuit is composed of two segments, the (1) peripheral dialysis segment and (2) central dialysis segment.

Peripheral dialysis segment: The portion of the dialysis circuit that begins at the arterial anastomosis and extends to the central dialysis segment. In the upper extremity, the peripheral dialysis segment extends through the axillary vein (or through the entire cephalic vein in the case of cephalic venous outflow). In the lower extremity, the peripheral dialysis segment extends through the common femoral vein. The “perianastomotic” segment is defined as part of the peripheral dialysis segment. Any intervention in the perianastomotic region is therefore reported with the new codes and is no longer separately reported as an arterial intervention.

Central dialysis segment: Includes all draining veins central to the peripheral dialysis segment. In the upper extremity, the central dialysis segment includes the veins central to the axillary and cephalic veins, including the subclavian and innominate veins through the superior vena cava. In the lower extremity, the central dialysis segment includes the veins central to the common femoral vein, including the external iliac and common iliac veins through the inferior vena cava. Other named or unnamed veins may be included in this segment. For instance, large collateral veins may develop in the neck to circumvent a stenosis or occlusion of the subclavian vein, draining into the central vein via the jugular vein. In this case, the large collateral veins and jugular vein are defined as part of the central dialysis segment.

GENERAL INSTRUCTIONS FOR THIS CODE SET

This code set is inclusive of most services provided. The codes are built on progressive hierarchies such that a single code is reported for all services provided in a segment of the dialysis access. One base code (36901–36906) is reported, using the code that describes the highest-intensity service provided. These codes include all punctures of and catheter manipulations from direct punctures of the dialysis circuit, all diagnostic imaging, all radiologic supervision and interpretation used to perform the diagnostic study and interventions, all road mapping, and all angiography, including completion angiography. Closure of the puncture(s) by any method, including suture, is included in each code in this family.

36901 describes a diagnostic fistulagram performed via direct puncture(s) of the dialysis circuit and includes imaging from the immediate inflow portion of the artery through the right atrium. All punctures of the dialysis circuit and all catheterizations of the dialysis circuit are included in 36901. It is not required that the entire circuit is imaged to report this code, but CPT specifies that all necessary imaging be performed. It is expected that in most cases, the entire circuit would be studied in keeping with national guidelines, but it is recognized that occasionally an entire diagnostic study is not needed or indicated. 36902–36906 also include the services of 36901 when performed, and 36901 is not reported in addition to 36902–36906.

36902 describes balloon angioplasty of the peripheral dialysis segment performed from direct punctures of the dialysis circuit. It is reported once regardless of the number of lesions treated, number of balloons used, or type of balloon(s) used (eg, plain balloon, high-pressure balloon, cutting balloon, drug-coated balloon [DCB]). Balloon angioplasty of the perianastomotic segment is reported using 36902.

36903 describes stent placement in the peripheral dialysis segment performed from direct punctures of the dialysis circuit. It is reported once regardless of the number of lesions treated and the number or type of stent(s) used (eg, self-expanding, drug-eluting, covered). It also includes any balloon angioplasty done in the peripheral dialysis segment, even if balloon angioplasty alone is performed on some lesions and stenting alone is performed on other lesions in the peripheral dialysis segment.

36904 describes a declot procedure of the dialysis circuit. This includes clot removal by any means from the peripheral and/or central dialysis segments and is reported once even if thrombus is treated in both the peripheral and central dialysis segments. This code also includes all direct punctures of the dialysis circuit and all catheterizations performed from direct punctures of the dialysis circuit. A diagnostic fistulagram is included in 36904; code 36901 is not separately reported.

36905 includes the services described by 36904 plus any balloon angioplasty in the peripheral dialysis segment performed via direct puncture(s) of the dialysis circuit. Similar to code 36902, all angioplasty performed in the peripheral dialysis segment is included in 36905, and the code is reported once regardless of the number of lesions treated with balloon angioplasty.

36906 includes the services described by 36904 and 36905, plus any stent placement performed in the peripheral dialysis segment when placed via direct puncture(s) of the dialysis circuit. This code is reported once regardless of the number of stents placed, number of lesions stented or treated with balloon angioplasty in the peripheral dialysis segment, or the type of stent(s) or balloon(s) used.

There are three add-on codes that may be additionally reported (36907, 36908, 36909). These codes are reported with 36901–36906. Codes 36907 and 36908 may also be reported with surgical codes 36818–36833 when central dialysis segment interventions are performed at the time of open surgical procedures for the dialysis circuit.

36907 describes angioplasty in the central venous segment when performed via a direct puncture of the dialysis circuit and includes all angioplasty performed in the central venous segment. Code 36907 is reported once, even if multiple stenoses are treated and multiple balloons are used and includes all types of angioplasty (eg, plain balloon angioplasty, cutting balloon, DCB).

36908 describes stenting in the central venous segment when performed from a direct puncture of the dialysis circuit. It includes all angioplasty and done in the central venous segment in addition to all stenting and is reported once regardless of the number of lesions treated and number or type of stents/balloons used.

36909 describes embolization of the circuit or side branches and is reported once regardless of the number of vessels treated or the number/type of embolic materials used. Code 36909 does not specify that the access must be through direct puncture of the dialysis circuit and is used regardless of the approach used. Code 37240 is not reported for embolization in the dialysis circuit, even if the vessels are approached from an access other than direct puncture of the dialysis circuit. If the approach is from direct puncture of the dialysis circuit, a base code (36901–36906) is reported with 36909, but no additional catheterization codes are reported, even if multiple side branches are selected to complete the embolization.

SERVICES NOT INCLUDED IN 36901–36909

Although the new codes include most of the services performed for dialysis access maintenance, there are components that may be separately reported when performed. These include:

Ultrasound guidance for puncture of the dialysis access (76937) may be separately reported when used for a failing or immature arteriovenous fistula (AVF). The required elements for reporting 76937 must be documented (assessment of vessel patency, use of ultrasound [US] to visualize needle entry into the vessel, and archival of an image to the patient’s permanent record) when this code is reported. CPT specifies that US guidance is not typically performed and also specifies that it is used for a failing or immature AVF, but fails to mention use for arteriovenous graft (AVG) punctures. It is not yet clear whether there will be limits to payment for this component, but clear documentation of the indication for use of US guidance would seem to be prudent.

Catheterizations performed from vessel punctures other than direct puncture of the dialysis circuit may be separately reported. Common femoral vein or artery, internal jugular vein, and brachial artery punctures are examples of alternative access sites that may be used to access the dialysis circuit. CPT specifies that these approaches are not used routinely and that the medical record must document the clinical indication for using an approach other than direct puncture of the dialysis circuit (CPT Assistant, March 2017). As an example, catheterization of a forearm AVF from a common femoral venous puncture would be separately reported with 36012.

Because codes 36901–36906 include the work of accessing the dialysis circuit, if the services are performed without puncturing the dialysis circuit (ie, from a separate access such as the femoral vein), the dialysis code would be reported with a -52 (reduced service) modifier, indicating that direct puncture of the AVF was not performed. For instance, if a diagnostic fistulagram were performed for a forearm AVF from a femoral vein puncture, 36901-52 would be reported with 36012. If punctures of both the femoral vein and the dialysis circuit were required to perform the diagnostic study, 36901 plus 36012 would be reported (without modifier -52).

It is not yet clear if there will be payment issues for those practices that routinely use alternate access sites, since CPT and CPT Assistant have been clear that alternative access sites are not typically indicated. Clear documentation of rationale for alternate puncture site(s) should always be given.

Diagnostic angiography of the inflow artery may be separately reported when performed to assess a suspected inflow problem. Evaluation of the arterial segment immediately above the perianastomotic segment/arterial anastomosis is included in 36901–36906 and would not be separately reported. However, 75710-59 may be separately reported when an extremity arteriogram is required (eg, suspected inflow abnormality, steal syndrome).

Selective catheterization of the inflow artery may be separately reported when required when diagnostic arteriography is performed to assess a suspected problem in the inflow vessel. In the arm, this would be reported with 36245-59. If the catheter is advanced into the aorta (eg, to fully assess a stenosis at the origin of the arch branch), 36200 is not additionally reported. Additional selective catheterization of the inflow artery is NOT reported when the catheter is advanced through the arterial anastomosis to complete the diagnostic fistulagram (36901) or to perform intervention of the perianastomotic segment or the peripheral dialysis segment. It is understood that to study and treat the arterial anastomosis, the catheter/wire must always be advanced into the inflow artery in the case of intervention and is sometimes advanced into the inflow artery to complete the diagnostic study. Therefore, advancing the catheter through the arterial anastomosis is included in codes 36901–36906 for all purposes of performing the study, the interventions, and follow-up imaging after intervention.

IVUS (37252, 37253) may be reported separately if used for diagnostic and/or therapeutic guidance.

Venous stenting (nondialysis vessel, 37238, 37239) may be reported for interventions in the central dialysis segment, but only when approached from punctures other than direct puncture of the dialysis circuit. When stenting of the central dialysis segment is performed from any puncture other than direct puncture of the dialysis circuit, 37238/37239 are reported. In this instance, the venous stenting codes are reported per anatomic vessel rather than the defined central dialysis segment “vessel.” Because the CPT descriptors for venous angioplasty (37248, 37249) specify that these codes are not to be reported for angioplasty in the dialysis circuit, they should not be reported for central venous angioplasty in a dialysis circuit, even when performed from an approach other than direct puncture of the dialysis circuit. In addition, the nondialysis venous and/or arterial angioplasty or stenting codes should not be reported for interventions in the peripheral dialysis segment, even when approached from a puncture other than direct puncture of the dialysis circuit.

CODING SCENARIOS

Case 1

A patient is seen for evaluation of a poorly developing AVF in the left forearm. Puncture of the AVF is performed, and a short catheter is advanced retrograde into the vein to near the arterial anastomosis. Imaging is obtained from the arterial anastomosis through the superior vena cava (SVC).

Coding: 36901. This same code would be used if the imaging were done through a needle instead of a catheter. All maneuvers used to enable visualization of the entire dialysis circuit are included in 36901.

Case 2

A patient is evaluated for poorly developing AVF in the left forearm. Antegrade and retrograde punctures of the dialysis circuit are performed, with catheters advanced retrograde through the arterial anastomosis and antegrade into the SVC to perform complete imaging of the entire dialysis circuit.

Coding: 36901. All catheterizations and punctures of the dialysis circuit are included in 36901. Even though an additional puncture was performed and more extensive selective catheterization was performed as compared with case 1, the coding is the same. Advancement of the catheter through the arterial anastomosis for completion of the diagnostic study is included in 36901. Imaging of the inflow artery immediately proximal to the arterial anastomosis is included in 36901.

Case 3

A patient is evaluated for poorly developing AVF in the left forearm. As in case 2, a diagnostic study is performed. A stenosis of the arterial anastomosis is identified and treated with balloon angioplasty, and the catheter is advanced retrograde beyond the arterial anastomosis for final imaging to document successful therapy.

Coding: 36902. The diagnostic study is included in 36902 and is not separately reported. The perianastomotic angioplasty is reported using the specific code for peripheral dialysis segment angioplasty, not a less specific code for arterial angioplasty.

Case 4

A patient is seen for failing dialysis access with prolonged bleeding and poor flows. The AVF is punctured in a retrograde direction and diagnostic study is performed, identifying stenosis at the arterial anastomosis as well as a focal stenosis in the outflow cephalic vein in the upper arm. These stenoses are treated with balloon angioplasty, requiring a second puncture in an antegrade direction to treat the cephalic vein stenosis. DCBs are used for each lesion, requiring two separate balloons.

Coding: 36902. This code includes the diagnostic study as well as all angioplasty performed in the peripheral dialysis segment, so it is reported only once. All punctures of the dialysis circuit are included in 36902 and are not separately reported.

Case 5

A patient is seen for failing dialysis access. Retrograde puncture of the access is performed, with advancement of the catheter tip through the arterial anastomosis. A stenosis of the arterial anastomosis is found, as well as a recurrent stenosis in a previously treated lesion in the cephalic arch at the shoulder. The arterial anastomosis is treated using balloon angioplasty, and the cephalic arch stenosis is treated using balloon angioplasty performed through a second puncture (antegrade), followed by stent placement due to inability to fully open the lesion with balloon angioplasty.

Coding: 36903. All angioplasty and stenting performed in the peripheral dialysis segment through direct puncture(s) of the dialysis circuit are included in 36903. Although separate lesions were treated with balloon angioplasty and stenting, only the highest-intensity code (stent placement) is reported. The diagnostic study is included in 36903, as well as all catheterizations.

Case 6

A patient presents with no flow in his AVF. The dialysis circuit is punctured using US guidance (with documentation of the required elements), and a fistulagram demonstrates thrombosis of the vein extending into the subclavian vein. A second puncture is performed, also using US guidance, and mechanical thrombectomy is used to clear the thrombus from the circuit. Tissue plasminogen activator (tPA) is infused into the thrombus as well. The arterial plug is removed by using a partially inflated angioplasty catheter to pull the plug into the fistula. Once flow is restored, a stenosis is identified in the outflow cephalic vein, which is opened with a covered stent.

Coding: 36906, 76937. Codes 36904, 36905, and 36906 include removal of thrombus from the dialysis circuit using any means and include removal from both the peripheral and/or central dialysis segments. These codes are reported once, even if thrombus is removed from both the peripheral and central dialysis segments, as was required in this case. Because stenting was also performed, the highest-intensity code including all services is 36906. Code 76937 is reported for use of US guidance and is reported once even though it was used for two separate punctures into the dialysis circuit.

Case 7

A patient presents with no flow in their AVG. Puncture of the dialysis circuit is performed under US guidance (with documentation of the required elements), and tPA is carefully laced into the vein and is allowed to dwell for 1 hour. The patient is then taken to the interventional suite, and the arm prepped and draped. A second puncture is made into the graft, and fistulagraphy is performed, which demonstrates thrombosis of the vein extending into the basilic vein at the mid-arm level. The thrombus is removed using mechanical thrombectomy, and a Fogarty catheter is used to remove the arterial plug. A stenosis of the subclavian vein is treated using balloon angioplasty, and a stenosis of the venous anastomosis is treated using balloon angioplasty.

Coding: 36905, 36907, 76937. Code 36905 includes declot of the fistula (and includes both the tPA lyse-and-wait as well as the mechanical thrombectomy and Fogarty balloon maneuvers), plus the angioplasty of the venous anastomosis. If the Fogarty balloon were the only balloon needed in the peripheral dialysis segment to remove the arterial plug, 36904 would be reported. Use of a balloon to remove the arterial plug is included in 36904. Balloon angioplasty of the central dialysis segment (subclavian vein) is reported using the add-on code 36907.

Case 8

Fistulagraphy is performed via a retrograde puncture of the dialysis circuit, which demonstrates recurrent stenosis within previously placed stents in the subclavian and innominate veins. A second puncture is performed into the dialysis circuit in an antegrade direction, and balloon angioplasty is performed in both areas of stenosis. Final imaging demonstrates opening of the stenosis with restoration of flow.

Coding: 36901, 36907. Code 36907 is an add-on code and must be reported with another code. It includes angioplasty of all stenosis treated in the central dialysis segment. Code 36901 is reported as the base code, because it represents the highest-intensity service performed in the peripheral dialysis circuit (diagnostic study). All catheterizations are included in codes 36901 and 36907.

Case 9

Fistulagraphy is performed via a retrograde puncture of the dialysis circuit, which demonstrates stenosis at the arterial anastomosis. In addition, stenoses are identified in the cephalic arch at the shoulder and in the innominate vein. The arterial anastomotic stenosis is treated with balloon angioplasty, the cephalic arch stenosis is treated with stenting after ballooning only partially opens the lesion, and the innominate vein stenosis is treated with balloon angioplasty.

Coding: 36903, 36907. Because the cephalic arch lesion and the arterial anastomosis lesion are both in the peripheral dialysis segment, a single code is used to report those two interventions, selecting 36903 for the highest-intensity service (stent) performed in this segment. The add-on code 36907 is reported for the angioplasty performed in the central dialysis segment.

Case 10

A patient is referred for new AVF that is slow to mature. Fistulagraphy is performed using antegrade puncture of the fistula. The fistula is manually occluded to force contrast retrograde and enable visualization of the proximal portions of the AVF, and then outflow imaging is performed through the SVC. The diagnostic study shows that the veins are patent, but two large side branches are found that are siphoning flow from the cephalic outflow vein. These veins are selectively catheterized, and angiography is performed in each of the branches to confirm anatomy and size. Each is then closed with a single coil.

Coding: 36901, 36909. Code 36901 is the base code reported and describes the fistulagram. Code 36909 is reported once for the embolization. These codes include all catheterizations performed from direct puncture of the fistula, as well as all diagnostic angiography performed. There is no additional coding for branch venography or branch selective catheterization. Follow-up angiography is included in 36909.

Case 11

A patient presents with failing AVF, including increased venous pressures, difficulty puncturing fistula, and prolonged bleeding after dialysis. The arm is swollen and bruised, so it is elected to approach the fistula from a remote puncture, and a right common femoral vein approach is chosen. The femoral vein is punctured, and a catheter is maneuvered into the left subclavian vein and then selectively maneuvered into the fistula in the left forearm. Diagnostic fistulagraphy is performed, demonstrating an arterial anastomotic stenosis plus a stenosis in the subclavian vein. The arterial anastomotic stenosis is treated with balloon angioplasty, and the subclavian vein stenosis is treated using a stent, all performed from the right femoral venous puncture.

Coding: 36902-52, 37238 (placement of venous stent), 36012 (second order selective venous catheterization). The -52 modifier for reduced services is appended to 36902 to signify that no puncture of the dialysis circuit was performed. Code 37238 is used to report the central dialysis segment stent placement, which was performed through a puncture other than direct puncture of the dialysis circuit.

Case 12

On day 1, a patient presents with suspicion of stenosis within their dialysis access. Fistulagraphy is performed via direct puncture of the fistula, documenting stenosis in the cephalic vein in the arm, as well as three separate central segment stenoses in the subclavian vein, the innominate vein, and the SVC. The operating physician is uncertain whether intervention can save this access, so the patient is referred to a surgeon. The surgeon determines that continued efforts to maintain this access should be made while options for a new access are explored. On day 2, the patient returns for treatment of all of the stenoses. Interventions are performed from a femoral venous approach, but no reason for using an approach other than direct puncture of the dialysis circuit is documented. No additional diagnostic studies are performed. Balloon angioplasty is used to treat all four areas of stenosis.

Coding for day 1: 36901; coding for day 2: 36902-52, 36907, 36012. On the first day, diagnostic fistulagraphy is performed and is reported with 36901. On the second day, the balloon angioplasty performed in the peripheral dialysis segment (cephalic vein) is reported with 36902 using a -52 modifier to signify a reduced service because the dialysis circuit was not punctured. Because 37248 and 37249 cannot be reported for angioplasty performed in the dialysis circuit, 36907 is the correct code and describes treatment of all three stenoses of the central segment. Because the -52 modifier used with 36902 accounts for the lack of direct puncture of the dialysis circuit, -52 may not be needed with 36907. Code 36012 is reported for the selective catheterization performed from the femoral approach. If the carrier audits this case, 36012 may be denied because no reason was documented for the need for an approach other than direct puncture of the dialysis circuit.

Case 13

The same patient as in case 12 returns on day 2 for treatment, which is again performed from a femoral puncture, but instead all four of the lesions are treated with stenting.

Coding for day 2: 36903-52, 37238, 37239, 37239, 36012. Code 36903 is reported for stenting of the peripheral segment stenosis (cephalic vein), with a -52 modifier to denote that direct puncture of the dialysis circuit was not performed. The stenting in the central dialysis segment may be reported using the nondialysis venous stenting codes because this was approached from the femoral vein rather than direct puncture of the dialysis circuit. In this case, three separate anatomic veins were treated (subclavian, innominate, and SVC) with stents. 37238 is reported once for the initial vein treated, and 37239 is reported twice for the two additional veins treated. Code 36012 is reported for the catheterization of the veins from the femoral puncture. Although multiple veins were catheterized, only the most selective one is reported, because the catheter passed through all the other areas of stenosis to reach the cephalic vein, with no additional branch selected.

Case 14

The patient presents for new right forearm AVF that is not maturing. Fistulagraphy is performed using a retrograde puncture performed under US guidance (with required elements documented). The tip of the catheter is advanced through the arterial anastomosis to allow visualization of the entire fistula. No stenosis is found.

Coding: 36901, 76937. If it is suspected that the failure to mature is due to an inflow stenosis, additional diagnostic work may be required. In this case, the catheter is selectively maneuvered to the origin of the innominate artery and right arm arteriography is performed. This demonstrates a stenosis in the right subclavian artery, which is treated with balloon angioplasty.

Additional coding: 37246-59, 36215-59, 75710-59. In this case, because a complete arteriogram was performed for specific suspicion of an inflow stenosis, and because the catheter was advanced retrograde to the more proximal artery, 75710 and 36215 are reported. A first-order selective catheterization is used, because as the catheter is maneuvered retrograde through the vessel, there is no vessel branching requiring additional selectivity as would be encountered when traversing this same vessel in an antegrade direction. If the catheter was advanced into the aorta, 36215 is still the correct code to report (36200 is included in the work of 36215 and would not be separately reported). Code 37246 is used to report balloon angioplasty of the subclavian artery, because the subclavian artery is a separate vessel and not part of the dialysis circuit. The -59 modifier is used with all of these codes to denote that they represent distinct procedural service, separate from the diagnostic study or any intervention performed in the dialysis circuit itself.

Case 15

The patient presents with a left arm AVF that is failing to mature. Diagnostic fistulagraphy is performed via retrograde puncture of the AVF, using US guidance for the puncture and documenting all required elements. No stenosis is identified, so intravascular ultrasound (IVUS) is used to obtain further diagnostic information. A second (antegrade) puncture is performed, and diagnostic IVUS is performed through the dialysis circuit in the peripheral segment, confirming no structural abnormality causing failure to mature.

Coding: 36901, 37252. In this case, all of the punctures are included in 36901, even though a separate puncture was performed specifically for the IVUS. In this case, because IVUS was performed only in the peripheral dialysis segment, 37252 is reported to include the entire dialysis “vessel” studied, rather than reporting IVUS per anatomic vessel.

Case 16

During surgical creation of a left arm direct AVF, fistulagraphy is performed, and a stenosis is found in the outflow cephalic vein in the upper arm. This is treated with balloon angioplasty, in addition to the planned revision of the arterial anastomosis.

Coding: 36821. The entire peripheral dialysis segment is considered the same surgical field as the arteriovenous anastomosis in surgical cases, so diagnostic study and any endovascular therapies performed in this territory during the surgical procedure are not separately reported. Although the stenosis in the cephalic outflow vein is remote from the surgical incision, it is not defined as a central dialysis segment vein and is thus not separately reported.

The central dialysis segment is not considered to be in the same surgical field as the arteriovenous anastomosis, and if stenosis was identified and treated in the central dialysis segment during this same surgical procedure, it could be reported using the add-on codes 36907 for balloon angioplasty or 36908 for stent placement. These two codes may be added on to the surgical codes 36818–36833 and do not require a code from the 36901–36906 series as a base code. When used in a surgical setting, the rules for use are the same as when used with the percutaneous codes 36901–36906. Only one of these codes would be reported, selecting the one inclusive of the highest intensity service performed, and that code is reported once for all interventions performed in the central dialysis segment. No additional catheterization code would be reported, as that is included in 36907 and 36908 when the access is direct into the dialysis circuit (whether percutaneous or open).

CONTACT US

If you have any questions or topics you would like Dr. Krol to address in a future column, please contact us at evteditorial@bmctoday.com.

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

 

Contact Info

For advertising rates and opportunities, contact:
Craig McChesney
484-581-1816
cmcchesney@bmctoday.com

Stephen Hoerst
484-581-1817
shoerst@bmctoday.com

Charles Philip
484-581-1873
cphillip@bmctoday.com

About Endovascular Today

Endovascular Today is a publication dedicated to bringing you comprehensive coverage of all the latest technology, techniques, and developments in the endovascular field. Our Editorial Advisory Board is composed of the top endovascular specialists, including interventional cardiologists, interventional radiologists, vascular surgeons, neurologists, and vascular medicine practitioners, and our publication is read by an audience of more than 22,000 members of the endovascular community.