Coding of Procedures in Interventional Nephrology 2018

ASDIN/RPA Coding Manual 2018

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Coding of Procedures in Interventional Nephrology 2018

Produced in collaboration with:


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INDEX SUBJECT PAGE Introduction viii How to Use This Manual viii Categories of Codes viii

Add-on Codes ix Physician’s Services Furnished on Day of Dialysis ix Separate Billing for Technical and Professional Services x Facility and Non-Facility Billing x National Correct Coding Initiative x Column 1 - Column 2 x Using a modifier xi Medically Unlikely Edits xi

Diagnostic RS&I code used in association with a therapeutic RS&I code xi

Patient Relationship Categories xii

1. Definitions 1

1.1 Arteriovenous access definitions 1

2. Angiography, angioplasty and stent placement in peripheral segment 1

2.1 Basic codes 1

2.1.1 Angiogram of dialysis access circuit 2

2.1.2 Angioplasty of peripheral segment 3

2.1.2.1 Angioplasty code not appropriate 3

2.1.3 Stent placement in peripheral segment 3

3. Angioplasty and stent placement in central segment 4

3.1 Central segment procedures 4

3.1.1 Angioplasty of central segment 5

3.1.1.1 Central vein not accessed through dialysis access circuit 6

3.1.2 Stent placement in central segment 6

3.1.2.1 Central vein not accessed through dialysis access circuit 6

4. Thrombectomy of dialysis access 7

4.1 Dialysis access thrombectomy codes 7

4.1.1 Thrombectomy only 7

4.1.2 Thrombectomy with angioplasty 7

4.1.3 Thrombectomy with angioplasty and stent placement 8

4.1.4 Failed thrombectomy 9

4.1.5 Thrombolytic infusion 9

4.1.6 Managing peripheral embolization associated with thrombectomy 9

4.1.6.1 Peripheral arterial embolectomy - upper extremity 9

4.1.6.2 Peripheral arterial embolectomy - lower extremity 11

4.1.6.2.1 embolectomy in lower extremity with arterial angioplasty 11

4.1.6.3 Special situations relating to embolectomy 11


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4.1.7 Delayed arterial embolus 11

5. Arteriovenous access procedures – arterial 12

5.1 Cannulation of brachial or radial artery 12

5.2 Arteriogram 12

5.2.1 Basic coding for arteriogram 12

5.2.2 Arteriogram performed with arterial angioplasty 13

5.3 Arterial angioplasty – upper extremity 13

5.4 Arterial angioplasty with stent placement - upper extremity 14

5.5 Arterial angioplasty - lower extremity 14

5.6 Arterial angioplasty with stent placement - lower extremity 14

6. Secondary codes for arteriovenous access procedures 15

6.1 Special procedures 15

6.1.1 Codes which may not be reported with primary codes 15

6.1.2 codes which may be reported with primary codes 15

6.2 Cannulation (catheterization) codes 16

6.2.1 Nonselective cannulation 16

6.2.2 Selective catheterization 16

6.2.2.1 Coding cannulation with basic dialysis access procedures (36901-6) 16

6.2.2.2 Selective catheterization – venous 19

6.2.2.3 Selective catheterization – upper extremity arterial 19

6.2.2.3.1 - Exception for the lower extremity 20

6.2.2.4 Dropping nonselective code when selective code is used 21

6.3 Aids for difficult cannulation 22

6.3.1 Ultrasound guidance 22

6.3.2 Target device 22

6.4 Sedation 22

6.4.1 Initial 15 minutes 23

6.4.2 Each additional 15 minutes 23

6.4.3 Sedation medications 23

6.5 EKG monitoring 24

7. Ultrasound of dialysis access 24

7.1 Ultrasound evaluation of dialysis access 24

7.1.1 Imaging by more than one modality 25

7.2 Use of ultrasound to assist dialysis access cannulation 25

8. Vascular mapping 25

8.1 Vascular mapping 26

8.1.1 Vascular mapping - no prior access 26

8.1.2 Vascular mapping - prior access 27

8.2 Angiographic study 27

8.2.1 Cannulation and injection of contrast 27

8.2.2 Venogram 27


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8.2.3 Superior vena cava angiogram 27

8.3 Ultrasound study 28

8.3.1 Ultrasound study of artery 28

8.3.1.1 Multiple imaging modalities on the same day 28

8.3.2 Ultrasound study of vein 28

9. Arteriovenous fistula - treatment of accessary vein 28

9.1 Common codes 28

9.1.1 Angiogram 29

9.2 Vein ligation 29

9.3 Embolization coil 29

9.3.1 Selective catheterization 29

9.3.2 Insertion of embolization coil 29

9.3.3 Management of complications - use of endovascular snare 30

10. Treatment of hand ischemia 30

10.1 Hand ischemia 30

10.1.1 Balloon assisted banding 31

10.1.2 Distal radial artery embolization 31

11. Tunneled catheter procedures 32

11.1 Primary codes 32

11.1.1 Insertion of tunneled catheter 32

11.1.2 Ultrasound guidance 33

11.1.3 Fluoroscopic guidance 33

11.1.3.1 Aid for difficult cannulation - using a target device 34

11.2 Secondary codes 34

11.2.1 Venous angioplasty 34

11.2.2 Aborted cannulation site 35

11.3 Evaluation of existing tunneled catheter 35

11.4 Tunneled catheter repair 36

11.5 Tunnelled catheter removal 36

11.5.1 Tunneled catheter removal (not replaced) 36

11.5.2 Tunneled catheter exchange 36

11.5.2.1 Same venous entry site 36

11.5.2.1.1 At non-tunneled catheter site 37

11.5.2.1.2 By “wiring-the-tunnel” 37

11.5.2.2 New venous access site 37

11.5.2.3 Venous angioplasty with catheter exchange 37

11.5.3 Fibrin sheath removal 38

11.5.3.1 Venous angioplasty performed in presence of fibrin sheath 39

11.5.4 Intraluminal removal of catheter thrombus 39

11.5.5 Intraluminal lytic enzyme 39

12. Non-tunneled catheter procedures 39


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12.1 Non-tunneled catheter procedures 39

13. Subcutaneous port procedures 40

13.1 Subcutaneous port procedures 40

14. Peritoneal catheter procedures 41

14.1 Primary codes 41

14.1.1 Insertion of peritoneal dialysis catheter, open surgery 41

14.1.2 Insertion of peritoneal dialysis catheter, laparoscopy or peritoneoscopy 41

14.1.3 Insertion of peritoneal dialysis catheter, percutaneous 41

14.1.4 Insertion of a subcutaneous extension to remote chest site 42

14.1.5 Injection of air/radiocontrast 42

14.1.6 Ultrasound evaluation prior to trocar insertion 42

14.2 Peritoneal dialysis catheter removal 42

14.2.1 Peritoneal catheter exchange 42

14.3 Repair of ventral hernia 43

14.4 Peritoneal dialysis catheter revision 43

14.5 Delayed creation of exit site from embedded subcutaneous segment 43

15. Fistula creation 43

15.1 Types of fistula 43

15.1.1 Simple direct fistula 43

15.1.2 Vein transposition fistula 43

15.1.3 Vein translocation fistula 43

15.2 Creation of fistula 44

15.2.1 Creation of simple direct fistula 44

15.2.2 Creation of vein transposition fistula 44

15.2.2.1 Brachial-basilic fistula 44

15.2.2.2 Brachial-cephalic fistula 45

15.2.2.3 Form vein transposition fistula 45

15.2.3 Creation of can translocation fistula 45

15.3 Secondary procedures 45

15.3.1 Revision of AVF/AVG 45

15.3.2 Revision of AVF/AVG with thrombectomy 46

15.3.3 Revision of AVF/AVG involving repair of aneurysm 46

15.3.4 Ligation/banding of AVF 46

15.3.5 Ligation of artery of extremity 46

15.3.6 Direct repair of vessel 47

15.3.7 Repair vessel with prosthetic graft 47

15.3.8 Repair vessel with vein graft 47

16. Adverse events 47

16.1 Adverse event 47

16.2 Cardiopulmonary resuscitation 47

16.3 Endotracheal intubation 47


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17. Modifiers 48

17.1 Modifiers 48

17.2 Failed procedure 48

17.2.1 Code only the procedure completed 48

17.2.2 Modifier for reduced level of service 48

17.2.3 modifier for discontinued procedure 48

17.3 Complex or complicated procedure 49

17.4 Separate professional service 50

17.5 Modifier -X{EPSU} for multiple distinct procedures 50

17.5.1 Modifier XE (separate encounter) 50

17.5.2 Modifier XP (separate practitioner) 50

17.5.3 Modifier XS (separate structure) 51

17.5.4 Modifier XU (separate unusual, nonoverlapping service) 51

17.6 Coding for bilateral surgery 51

17.7 Subsequent procedure performed during global period 51

18. Documentation 52

18.1 Documentation 52

Illustrative Coding Cases

Fistula Case 1 – AVF with Venous Stenosis in Access in Peripheral Segment 55

Fistula Case 2 – AVF with Two Venous Stenoses in Access in Peripheral Segment 56

Fistula Case 3 – AVF with Peripheral and Central Segment Stenoses 57

Fistula Case 4 – Juxta-Anastomotic and Anastomotic Stenosis 58

Fistula Case 5 – Juxta-Anastomotic and Anastomotic Stenosis with Venous Stenosis in Access 59

Fistula Case 6 – Anastomotic Stenosis with Venous Stenosis in Central Vein 61

Fistula Case 7 – Juxta-Anastomotic and Anastomotic Stenosis with Feeding Artery Stenosis 63

Fistula Case 8 - Juxta- Anastomotic Stenosis Approached from Radial Artery 65

Fistula Case 9 – AVF Thrombosis 66

Fistula Case 10 – AVF with Accessory Vein Treated with a Coil 68

Fistula Case 11 – AVF with Accessory Field of Veins Treated with a Coil 69

Fistula Case 12 – AVF with Two Accessory Veins Treated with Coils 71

Fistula Case 13 – AVF with Accessory Vein and Misplaced Coil 73

Fistula Case 14 – AVF with Accessory Vein Treated by Ligation 75

Fistula Case 15 – Brachial-Cephalic Fistula with Dialysis Access Steal Syndrome 76

Fistula Case 16 – AVF with Hand Ischemia Due to Arterial Lesions 78

Fistula Case 17 – Radial-Cephalic Fistula with Dialysis Access Steal Syndrome 80

Graft Case 1 – Thigh AVG with Venous Stenosis and Arterial Anastomosis Stenosis 82

Graft Case 2 – AVG with Thrombosis and Both Arterial and Venous Stenosis 84

Graft Case 3 - AVG with Thrombosis Treated Leaving Residual Clots 86

Graft Case 4 – AVG with Thrombosis and Peripheral Artery Embolus 88


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Graft Case 5 – AVG with Thrombosis and Delayed Peripheral Artery Embolus 90

Graft Case 6– AVG with Thrombosis, with separate Remote Thrombus 91

Graft Case 7 – Thrombosed HeRO Device 93

Stent Case 1 – Grade 3 Rupture Requiring Stent 95

Stent Case 2 - Long Elastic Lesion Requiring 2 Stents 96

Stent Case 3 - Central Venous Stenosis Requiring a Stent 97

Stent Case 4 - Peripheral and Central Veinous Stenosis Both Requiring a Stent 98

Stent Case 5 - Arterial Anastomosis and Peripheral Artery Stenosis Both Requiring a Stent 100

Stent Case 6 – Stent Placed from Non-Dialysis Access Site 102

Catheter Case 1 –TDC Insertion 104

Catheter Case 2 – TDC Insertion with Stenosis of Right IJ 105

Catheter Case 3 – TDC Insertion with Obstructed Right IJ 106

Catheter Case 4 – TDC Insertion with Obstructed Right IJ Using Target for Cannulation 107

Catheter Case 5 – TDC Exchange at Same Site 109

Catheter Case 6 – TDC Exchange with Change of Site 110

Catheter Case 7 – TDC Exchange with Fibrin Sheath 111

Catheter Case 8 – TDC Exchange with Fibrin Sheath and Venous Stenosis 112 Catheter Case 9 – TDC Exchange with Complicated Central Vein Stenosis 114

Catheter Case 10 - TDC Exchanged for Acute Catheter 115

Catheter Case 11 – TDC Inserted by Wiring the Tunnel 116

PD Catheter Case 1 – PD Catheter Insertion Using Percutaneous Technique 117

PD Catheter Case 2 – PD Catheter Insertion Using Peritoneoscope 118

PD Catheter Case 3: PD Catheter Insertion by Peritoneoscopy with Imaging 119 PD Catheter Case 4: Radiocontrast Injection and Manipulation of PD Catheter 120 PD Catheter Case 5: PD Catheter Removal with Repair of Ventral Hernia 121

PD Catheter Case 6: PD Catheter Exchange 122


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Introduction

The Renal Physician's Association (RPA) and The American Society of Diagnostic and Interventional

Nephrology (ASDIN) published their first joint Coding manual in 2005. Since then, because the coding of

dialysis vascular access procedures has continued to evolve, annual updates have been published. During

this period, the ASDIN-RPA Coding Manual has come to represent the standard of practice for coding

procedures in interventional nephrology. There are no substantial changes in the codes used for dialysis

access endovascular procedures for 2018. Only minor changes and required corrections have been made

in this Coding Manual. We strongly encourage readers to adhere to this guideline in their procedural coding

to ensure both consistency and accuracy of coding.

Notice

This document is informational only and should serve as a guideline for appropriate coding. CPT codes and their descriptors are

copyrighted by the American Medical Association. Codes should be strictly applied in a manner consistent with coverage and

payment policies including National and Local Coverage Determination Policy for specific rules in your area. This manual is

designed to provide accurate and authoritative information regarding coding principles and reasonable efforts have been made to

assure the accuracy of the information within the pages. However, the ultimate responsibility for correct coding /documentation

remains with the provider of service. ASDIN makes no representation, warranty, or guarantee that this compilation of information

is error-free, nor that the use of this guide will prevent differences of opinion or disputes with the Medicare carrier as to the codes

that are accepted or the amounts that will be paid to providers of service, and will bear no responsibility or liability for the results

or consequences of this guidance.

How to Use this Manual

Given the variety of interventional procedures being performed for dialysis access maintenance and salvage,

there are a large number of CPT codes with which one must be familiar. To establish some type of logical

organization, the codes described herein have been grouped by procedure to the degree that it is possible.

By looking under a heading such as angioplasty, all the codes that might be used during the conduct of that

procedure are listed together. By necessity, there is overlap. In these cases, reference will generally be made

back to the first listing for that code rather than be excessively repetitious.

Prior to coding for interventional procedures, it is the recommendation of this committee that the appropriate

sections of the CPT manual be reviewed.

Categories of Codes

Different categories of services have different code series. For example, medicine uses 9xxxx codes, surgery

uses 3xxxx codes and radiology uses 7xxxx codes. These code series relate to the type of service not the

speciality of the physician providing the service. Any physician can use any code when appropriate. For the

types of procedures performed for dialysis access maintenance and salvage the 3xxxx and 7xxxx series are

used primarily. In the past, some interventional coding was composed of two related codes, a 3xxxx code for

the performance of the procedure (surgical service) and a 7xxxx code for the supervision and interpretation

of the imaging performed (radiological service). For the codes most frequently used (36901-36908), the

radiological supervision and interpretation component has been bundled with the primary code and is not


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listed separately. In addition, modifiers can be attached to a CPT code to better define a specific service that

may represent a second, incomplete or more complex procedure. The modifiers that are most commonly

applied to the procedures described in the Manual are listed in Section 12. A more detailed listing can be

found in the AMA CPT coding manual.

Add on Codes

Add-on codes enable physicians to separately identify a service that is performed in certain situations as an

additional service or commonly performed supplemental service to the primary service/procedure performed.

For example, if a central angioplasty and a peripheral angioplasty are both performed, the primary code

should be 36902 for the peripheral angioplasty and the central angioplasty should be coded with the add-on

code +36907. Add-on codes are reimbursable services when reported in addition to the appropriate primary

service or procedure, but cannot be used as stand-alone codes. By themselves they are not reimbursable.

A CPT code is designated as an add-on code in the AMA CPT manual by the designation (+) placed next to

the code. In addition, the code descriptors for all add-on codes contain a variation of the phrase “List

separately in addition to code for primary procedure.” Some MAC’s have required that a X{EPSU}

modifier be attached to the code. However, while this designates the code as “multiple distinct procedure”

add-on codes are exempt from the multiple procedure discount. This means that as discussed in the

section on modifiers they are exempt to the depreciated value that occurs when multiple procedures are

otherwise performed. Add-on codes have a discounted value that was built in at the time the relative value

units (RVU) were assigned.

Physician’s Services Furnished on Day of Dialysis

A physician’s service that is provided to a dialysis patient is covered regardless of whether it is performed on

the day of dialysis provided it meets the CMS requirements defining a physician’s service and is deemed to

be medically necessary. Supervision or direction of a dialysis treatment by a physician does not ordinarily

meet the CMS requirement for physician’s services and, therefore, is not paid for as such under the CMS fee

schedule. However, payment for a physician’s services is made if the service is not related to the treatment

of the patient’s ESRD, and the service was not, and could not have been, furnished during the dialysis

treatment. A physician’s surgical services (catheter insertion, angioplasty, thrombectomy) represents such

a case. These services should be billed under the appropriate procedure code for payment. If more than one

physician furnishes care to the same dialysis patient, the usual coverage rules on concurrent care should be

followed (see modifiers - Para 17).

Often, a claim from a physician who files a procedure code for additional services furnished to a patient on

the day of dialysis will be reviewed by CMS medical staff prior to payment. Therefore, good documentation

is necessary. Using the specific wording that the service provided was “surgical and was not and

could not have been provided during the dialysis treatment” seems appropriate.


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Separate Billing for Technical and Professional Services (Modifier 26)

In general, CMS makes a single payment for all covered services, which includes ancillary services that are

furnished in connection with a covered procedure. They do, however, designate certain radiological services

(7xxxx series codes) that are eligible for separate payment for the technical and the professional component.

This is possible only if the services are performed in a facility in which the physician does not own the

equipment nor employ the technical staff. These eligible services are billed by attaching a modifier to the

basic code, TC for the technical and 26 for the professional component. If the code for the procedure is used

unmodified, it indicates a complete or global service and the total payment is due to the operator.

If the physician owns the equipment and employs the technical staff or if the physician is employed directly

by the facility to provide professional services for which the facility does the billing, the global designation (no

modifier should be used.

This principle, the ability to use a 26 and TC modifier, applies only for procedures performed in the hospital.

None of the radiological codes (7xxxx series codes) used in this manual have been designated as eligible for

separate payment under this mechanism in an ambulatory surgical center. It also does not apply in the

extension of doctor’s office model (POS 11). The 3xxxx series and the 9xxxx series codes are not affected

by this policy.

Facility and Non-Facility Billing

In the extension of doctor’s office model, payment is made under the Medicare Physician Professional Fee

Schedule (PPFS). The PPFS lists a “facility” and “non-facility” payment. The non-facility payment is to be

utilized for payment of physicians who are performing procedures in their own office facility. This higher

reimbursement is intended to reimburse both the physician’s professional work and the facility costs related

to the procedure. The facility payment includes only the physician’s direct professional service

reimbursement assuming the procedure is being performed in a facility that he/she does not own.

CCI edits are editorial comments that are issued to clarify coding issues. If there is a special restriction or

requirement for the use of a specific CPT code, it will be published as a CCI Edit. CCI Edits are updated

quarterly; updates should be ordered and reviewed quarterly.

National Correct Coding Initiative

CMS expanded the reach of the National Correct Coding Initiative (NCCI), effective Jan. 1, 2009. The NCCI

edits, built into the Medicare contractors' claims processing systems, control improper payment of Part B

claims by disallowing certain combinations of CPT codes to be billed together, or by limiting the payable

number of units for some services. The NCCI contains two types of edits: the Column 1/Column 2 edits,

and the Medically Unlikely Edits (MUEs).

Column 1 - Column 2 - Column 1 - Column 2 code edits get their name from the table in which they appear.

The CPT codes appearing in Column 1 are the payable service. The codes in Column 2 are the non-payable

codes (unless they qualify for an appropriate modifier). The column 1/column 2 correct coding edit table


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contains two types of code pair edits. In effect, the edit bundles the Column 2 service into the Column 1

service when either:

Column 2 (component) is an integral part of Column 1 (comprehensive), or when

Column 1 and Column 2 could not reasonably, based on medical necessity, be provided to the same patient

on the same day by the same physician

The National Technical Information Service (NTIS) provides the printed versions of column 1/column 2 correct

coding edits and CMS provides the electronic version. The column 1/column 2 edits table is divided into 6

columns:

• Column 1 is the payable code in the edit pair

• Column 2 is the non-payable code in the edit pair

• Column 3 shows whether an edit pair was established before 1996

• Column 4 shows the first effective date of the edit

• Column 5 shows the deletion date of the edit.

• Column 6 shows whether exceptions are allowed for billing the code pair

When reported with the column 1 code, the column 2 code generally represents the code with the lower work

RVU of the two codes. Some column 1/2 codes are mutually exclusive. In this instance column 6 of the table

will list a “0.” This means that if both procedures are reported, only the column 1 code will be paid. In other

words, the column 2 code is dropped in favor of the higher-level column 1 code.

Using of a modifier with column 1 - column 2 code pairs - In this instance, column 6 of the table will list

a “1.” This means that the two procedures can be coded together and both procedures will be paid, but a

modifier will need to be attached to the column 2 code. This would require that one of the X{EPSU} modifiers

be used. (see discussion in Para 17.5 for discussion of how these modifiers are used). It should be noted

that the same code can be a column 1 code when paired with one code and a column 2 code when paired

with a different code.

Medically Unlikely Edits – A medically Unlikely Edit (MUE) for a CPT code sets the maximum number of

units that a physician would report under most circumstances for a single beneficiary on a single date of

service. The MUE is based on the natural anatomic limits, the HCPCS and CPT code descriptors, CPT coding

instructions, CMS policies, the nature of service/procedure, the nature of equipment, and the physician's

clinical judgment. Accordingly, if the MUE is “2,” the physician cannot be paid for more than 2 units of that

code for a single patient on a single date of service. It should be noted that not all HCPCS/CPT codes have

MUEs associated with them.

Diagnostic RS&I Code Used in Association with a Therapeutic RS&I Code - There are a number of

procedures that involve both a surgical (30000 series) and a radiological or RS&I (70000) code. These RS&I


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codes roughly fall into two categories – diagnostic such as the performance of an angiogram and therapeutic

such as the radiological portion of an angioplasty.

Any vascular diagnostic or therapeutic procedure may be coded with one or more surgical codes and with

one or more RS&I codes. Some surgical codes are all-inclusive for use when the procedure has been valued

to include all of its surgical and imaging aspects. As a result, diagnostic and therapeutic procedures are often

performed during the same encounter. When a diagnostic RS&I code is used in association with a

therapeutic RS&I code, an -XU modifier should be attached to the former.

There is an exception to this rule. When the code 76937 (ultrasound guidance for vascular access) is used

for cannulation of other than catheter placement, there is no NCCI edit that requires the use of the modifier.

In other words, even though a therapeutic radiological S&I is used concurrently, 76937 does not require an

XU modifier. In all other instances in which the 76937 may be used, the requirement still exists.

Patient Relationship Categories - As part of the Medicare Access and CHIP Reauthorization Act (MACRA),

CMS has created a list of patient relationship (PRC) categories and codes. These codes will be listed a new

category of Healthcare Common Procedure Coding System (HCPCS) Level II modifiers. These codes would

be part of the billing for a CMS covered service along with the appropriate CPT and other HCPCS codes. It

is envisioned that would first report a CPT Code (Level I HCPCS) and then identify a Level II HCPCS modifier to

identify their relationship to the patient. As of yet, specific 6-digit alphanumeric code designations for this category

have not been assigned. They are listed as X codes 1 to 5.

The PRC categories and codes list has been distributed to carriers with the recommendation that their use

be initiated starting in January 2018. Voluntary reporting of the five PRC modifiers on Medicare claims is

effective for items and services furnished by a physician starting Jan. 1, 2018; however, use of the modifiers

is not a condition of Medicare payment at this time. It is anticipated that at some point this will change, and

their use will be required. Therefore, it is considered prudent that physician providers start to become familiar

with the system. When examining the list, it is apparent that an interventional nephrologist caring for a group

of dialysis patients could from time to time fall into any of several of the categories. The codes currently

assigned to the categories aures follows:

X1 - Continuous/broad: This category could include clinicians who provide the principal care for a patient,

where there is no planned endpoint of the relationship. Care in this category is comprehensive, dealing with

the entire scope of patient problems, either directly or in a care coordination role.

Example: Physician providing long-term comprehensive care (primary care) in addition to specialty care for

patient.

X2 - Continuous/focused: This category could include a specialist whose expertise is needed for the

ongoing management of a chronic disease or a condition that needs to be managed and followed for a long

time.


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Example: Nephrologist providing care for renal patient longitudinally but not providing general primary care

services.

X3 - Episodic/broad: This category could include clinicians that have broad responsibility for the

comprehensive needs of the patients, but only during a defined period and circumstance, such as a

hospitalization.

Example: Physician providing comprehensive and general care to a patient while admitted to the hospital.

X4 - Episodic/focused: This category could include a specialist focused on particular types of time-limited

treatment. The patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some

other type of generally time-limited intervention.

Example: Nephrologist seeing a consult and assuming responsibility for time-limited nephrology related care

while in the hospital. Providing acute dialysis services for hospitalized patient who is expected to recover

renal function.

X5 - Only as ordered by another clinician: This category could include a clinician who furnishes care to

the patient only as ordered by another clinician. This relationship may not be adequately captured by the

alternative categories suggested above and may need to be a separate option for clinicians who are only

providing care ordered by other clinicians.

Example: Interventionalist performing an angioplasty, thrombectomy or catheter placement on patient

referred by another clinician.

RPA/ASDIN Coding Manual 2018

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1. DEFINITIONS

1.1 - ARTERIOVENOUS ACCESS DEFINITIONS

The coding of arteriovenous access procedures requires an understanding of the definitions that are used

(Figure 1). The dialysis access circuit begins at the arterial anastomosis and ends at the right atrium. This

circuit is defined as having two segments: 1) a peripheral segment and 2) a central segment. The

peripheral segment includes the short length (2 cm) of artery adjacent to the arterial anastomosis up through

the axillary vein. The central segment includes the central veins – subclavian, brachiocephalic and superior

vena cava. In the lower extremity, the dialysis access circuit is defined similarly. The peripheral segment

includes the short segment (2 cm) of artery adjacent to the arterial anastomosis up through the femoral vein.

The central segment includes the central veins which are the external iliac vein, common iliac vein and inferior

vena cava. The arterial inflow to the dialysis circuit is considered a separate vessel for coding purposes.

2. ANGIOGRAPHY, ANGIOPLASTY AND STENT PLACEMENT IN PERIPHERAL

SEGMENT

2.1 - BASIC CODES

Three bundled codes are used for angiography, angioplasty and stent placement in the peripheral

segment. (Table 1). These codes are utilized in the dysfunctional, but not thrombosed dialysis access

circuit. It should be noted that only one of these codes can be used in each case and can be used only once;

however, they can be used with the add-on code series for angioplasty of the central veins (36907-8). These

codes bundle all components of the procedure related to the peripheral segment of the dialysis access

circuit including cannulation, selective catheterization, all imaging and radiological supervision and


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interpretation. However, they do not include procedures done to image or intervene upon the arterial inflow

to the dialysis access (more than 2cm proximal to the arterial anastomosis).

2.1.1 Angiogram of dialysis access circuit

The code for an angiogram of the dialysis access circuit is 36901 (Table 1). The descriptor for this code is -

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).


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As is indicated in the descriptor for 36901, cannulation of the access is included in the bundle. The code

includes angiographic evaluation of the entire dialysis access circuit including the arterial anastomosis and

adjacent artery (Figure 1). The term “adjacent artery” should be taken to mean the immediately adjacent 2

cm segment. It also includes angiographic evaluation of the entire venous outflow including any vein

branches to the right atrium. Radiocontrast used for the angiogram is also bundled. All cannulation

and selective catheterizations necessary for imaging or intervening within the dialysis circuit are also

included in 36901-6 (see Para 6.2.2 and subparagraphs).

Coding tip: The inclusion of selective catheterization with 36901 only relates to that which is done in order to image the dialysis

circuit. Selective catheterization performed for other indicated purposes is not included.

2.1.2 - Angioplasty of Peripheral Segment

The code for an angiogram with angioplasty of the peripheral segment of the dialysis access circuit is 36902

(Table1). (This code should be used whether the access is in the upper or lower extremity. The descriptor

for this code is - 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; with transluminal balloon angioplasty, peripheral dialysis segment, including all

imaging and radiological supervision and interpretation necessary to perform the angioplasty.

The code 36902 can be used only once in the peripheral segment. It should be noted that when this code

is used it includes all those components described in code 36901. Therefore, these two codes cannot be

used together, only the higher-ranking code should be listed.

A stenosis of 50% or greater as well as a clinical indication (poor flow, abnormal exam, prolonged

bleeding, etc.) should be required prior to performing an angioplasty. The degree of stenosis should always

be documented in the procedure report and image files.

Coding Tip: Where the exact percentage of stenosis cannot be stated with certainty, a statement such as “greater than 50%” or

“near complete obstruction” should be made to provide adequate documentation of a degree of stenosis to warrant the angioplasty

procedure. Images objectively demonstrating the stenosis are required

2.1.2.1 Angioplasty code not appropriate

Angioplasty performed on a vein that is not stenotic (diseased) should not be coded as an angioplasty.

However, when treating a non-maturing AVF, a venous segment that is of smaller caliber than would be

normally expected for that period of maturation should be classified as stenotic.

2.1.3 Stent Placement in Peripheral Segment

The code for angiography, angioplasty and stent placement in the peripheral segment of the dialysis access

circuit is 36903 (Table 1). The descriptor for this code is - Introduction of needle(s) and/or catheter(s), dialysis

circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter


4

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; with transcatheter placement of

intravascular stent(s) peripheral dialysis segment, including all imaging and radiological supervision and

interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis segment.

As indicated in the descriptor, 36903 bundles all the work included in the two lower level codes of the

hierarchy and these two codes cannot be also listed. As is the case with these two codes, 36903 includes all

the work related to the procedure on the dialysis access circuit. It can be used only once in each case even

if more than one stent was placed.

3 - ANGIOPLASTY AND STENT PLACEMENT IN CENTRAL SEGMENT

3.1 - CENTRAL SEGMENT PROCEDURES

There are two codes for angioplasty or stenting within the central segment of the dialysis access circuit – the

central veins. These codes are 36907 and 36908 (Table 2). The descriptor for both codes specifies the

procedure is done through the dialysis circuit. If a different approach (i.e. femoral vein) is utilized, these

codes do not apply. The code for central vein angioplasty performed from a non-dialysis access circuit site

is 37248 and additional, separate stenoses in different central veins are coded with add-on code +37249.


5

Since these are add-on codes, they must be used with a primary code. The appropriate primary code would

depend upon the primary procedure that was performed. If the primary procedure was on a dysfunctional

(non-thrombosed) dialysis access circuit, one of codes 36901-3 should be used. If the primary procedure

was a thrombectomy, one of the 36904-6 codes (see below) should be used. Only one add on code 36907

or 36908 can be used in a case, no matter how many separate central vein lesions are treated. Since it will

be paired with a primary code and it can also be used only once, there is a potential for no more than two

coded angioplasties in any given case.

Figure 2 – Lesion bridges from cephalic arch into subclavian vein. a - The lesion is primarily in the subclavian and should be

classified as a subclavian lesion. b - The lesion is about equally distributed between the cephalic and subclavian; it should be

classified as the higher order vessel – the subclavian. c - The lesion is primarily in the cephalic and should be classified as a

cephalic lesion.

If a single lesion bridges across two adjacent separate vessels, treatment warrants only a single

angioplasty code regardless of the location of the lesion. In instances in which the exact anatomical identity

of the vessel is critical for coding purposes, e.g., central versus peripheral (Figure 2). A lesion that bridges

across two vessels should be defined by the vessel in which it lies predominantly. Two codes are warranted

only in instances in which separate distinct lesions are present in separate vessels, provided that the

two vessels qualify for separate coding based upon the peripheral versus central segment rule as described.

3.1.1 - Angioplasty of Central Segment

A separate unique code, +36907 (Table 2), is used for an angioplasty performed in the central segment of

the dialysis access circuit (Figure 1). The descriptor for this code is - Transluminal balloon angioplasty,

central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision

and interpretation required to perform the angioplasty (List separately in addition to code for primary

procedure).

As indicated in the descriptor, the code +36907 includes all work related to the performance of the

angioplasty, but does not include the diagnostic angiogram. This aspect of the procedure is covered in the

primary procedure code (36901-3) to which it is added. This code, + 36907, can be used only once in any

given case. Additionally, 36907 can only be used when the central vein angioplasty is performed via the


6

dialysis access circuit – in other words only from a site of cannulation within the dialysis access

circuit.

3.1.1.1 Central vein not accessed through dialysis access circuit

If central venous angioplasty is done from a non-dialysis access circuit cannulation approach (i.e.

femoral vein), the code is 37248. The descriptor for this code is – transluminal balloon angioplasty (except

dialysis circuit), open or percutaneous, including all imaging and radiologic interpretation necessary to

perform the angioplasty within the same vein, initial vein. This code includes angioplasty and imaging

necessary to perform the angioplasty but does not include non-selective or selective cannulation and

catheterization which should be coded separately. The code 37248 includes all angioplasty within the

named vein, no matter the number of distinct stenoses. However, additional angioplasty done in different

central veins may be coded separately using 37249. The descriptor for this code is - transluminal balloon

angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiologic interpretation

necessary to perform the angioplasty within the same vein, each additional vein. The codes 37248 and 37249

are not for use when the angioplasty is done from a cannulation site within the dialysis circuit – from

a dialysis access circuit approach.

.

3.1.2 - Stent Placement in Central Segment

The code for stent placement in the central segment of the dialysis access circuit is +36908 (Table 2). The

descriptor for this code is - Transcatheter placement of an intravascular stent(s), central dialysis segment,

performed through dialysis circuit, including all imaging radiological 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). This is also an add-on code. As is the case with +36907, it must be used with a

primary code and the options would be the same as those listed above for that code.

As indicated in the descriptor, the code +36908 includes all work related to both the performance of the

angioplasty and stent placement, but does not include the diagnostic angiogram. This aspect of the

procedure is covered in the primary procedure code (36901-3) to which it is added. This code, + 36908, can

be used only once in any given case.

3.1.2.1 Central vein not accessed through dialysis access circuit

If central venous stenting is performed from a non-dialysis circuit cannulation approach (i.e. femoral

vein), the code is 37238. The descriptor for this code is – transcatheter placement of an intravascular stent(s),

open or percutaneous, including radiologic interpretation and including angioplasty within the same vessel

when performed, initial vein. This code can only be reported once no matter the number of stenoses or stents

used within that vein. However, if an additional stent(s) is placed in a separate vein to treat other

stenosis(es), it may be coded separately using 37239. The descriptor for this code is - transcatheter

placement of an intravascular stent(s), open or percutaneous, including radiologic interpretation and including

angioplasty within the same vessel when performed, each additional vein. The codes 37238 and 37239 are

not for use when the angioplasty is done from a cannulation site within the dialysis circuit, i.e., from

a dialysis access circuit approach.


7

4. THROMBECTOMY OF DIALYSIS ACCESS CIRCUIT

4.1 - DIALYSIS ACCESS CIRCUIT THROMBECTOMY CODES

There are three primary codes, 36904-6, that cover thrombectomy procedures of the dialysis access circuit

(Table 3). As with the angioplasty series of codes 36901 – 3, these codes are bundled – inclusive of all

diagnostic and intervention within the dialysis access circuit (not including the central segment

angioplasty or stent). Each higher-level code includes all the work covered in the lower level code(s). These

codes include all the work required to remove the thrombus from the peripheral and central segments of

the dialysis access circuit and restore flow to the access regardless of the method used, whether

mechanical or pharmacological. However, not covered are any pharmacological agents that might be

administered. If tPA (alteplase) is used, then the code J2997 should be applied. This code is for 1 mg of

the drug. If more than this is used, then the code may be used more than once. Treatment of an occlusion

without demonstrated thrombus is not a thrombectomy and should not be reported using these

codes.

It should also be emphasized that it is never appropriate to code removal of the arterial plug during a

thrombectomy procedure as an angioplasty. Removal of the arterial plug is included in the work of

thrombectomy 36904, even if a balloon catheter is used to mechanically dislodge a resistant thrombus.

4.1.1 - Thrombectomy only

The code 36904 (Table 3) is used for a case in which only a thrombectomy was performed without any other

secondary procedures in the peripheral segment of the dialysis circuit such as angioplasty or stent placement.

The descriptor for this code is - Percutaneous transluminal mechanical thrombectomy and/or infusion for

thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and

interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural

pharmacological thrombolytic injection(s).

Cannulations and the diagnostic angiogram are bundled with this code. This code cannot be used with any

of the 36901-3 codes; however, it can be used with the add-on code series for angioplasty of the central

veins (36907-8).

4.1.2 - Thrombectomy with angioplasty

The code 36905 is designated for use when an angioplasty is performed in the peripheral segment in

conjunction with the thrombectomy procedure (Table 3). The descriptor for this code is - Percutaneous

transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method,

including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic

guidance, catheter placement(s), and intra-procedural pharmacological thrombolytic injection(s); with

transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological

supervision and interpretation necessary to perform the angioplasty.


8

As a bundled code, it includes all the work involved with the performance of both procedures. This

code can be used only once even though more than one angioplasty may be performed. This code can also

be used with the add-on code series for angioplasty of the central veins (36907-8), but not with the 36901-3

codes.

4.1.3 - Thrombectomy with angioplasty and stent placement

In a case in which a stent is placed in addition to and angioplasty done in conjunction with a thrombectomy,

the code 36906 (Table 3) is used. The descriptor for this code is - Percutaneous transluminal mechanical

thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and

radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter

placement(s), and intraprocedural pharmacological thrombolytic injection(s); with transcatheter placement of

an intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and

interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis circuit.


9

As is the case with the other members of this group, the code 36906 includes all the work involved with

the performance of all three procedures: thrombectomy, angioplasty and stent placement. This code

can be used only once even though more than one stent may be placed. As is the case with other members

of this group, this code cannot be used with any of the 36901-3 codes; however, it can be used with the

add-on code series for angioplasty of the central veins (36907-8).

4.1.4 - Failed Thrombectomy

Not every thrombectomy procedure is successful, even after considerable effort, some cannot be

successfully treated. When coding such a procedure, only the portion of the procedure that was

completed should be considered. The thrombectomy codes should be utilized only if thrombus was

demonstrated and addressed by mechanical or pharmacological measures. If cannulation, thrombectomy

and angiogram is done but no other intervention can be performed (i.e. occluded outflow that cannot be

crossed), then coding should be 36904. If thrombectomy is not done and only the cannulation and angiogram

were completed before the procedure was abandoned, it should be coded as 36901. If in addition, the

angioplasty was successfully performed, the intended “thrombectomy” procedure should be coded as 36902.

4.1.5 - Thrombolytic Infusion

There are occasions in which rather than perform a thrombectomy or because a thrombectomy is not

successful and the decision is made to do an infusion of thrombolytic agent into the vessel. If the vessel is

an artery, the code for this procedure is 37211. The descriptor for this code is - transcatheter therapy, arterial

infusion for thrombolysis other than coronary, any method, including radiological supervision and

interpretation, initial treatment day. If the vessel is a vein, the code for the procedure is 37212. The

descriptor for this code is - transcatheter therapy, venous infusion for thrombolysis other than coronary, any

method, including radiological supervision and interpretation, initial treatment day.

It should be noted that these codes should only be used if the thrombolytic agent is used during a separate

procedure, not as a continuation of an embolectomy procedure (see below). The embolectomy code is all

inclusive and covers any method that might be used, including the administration of a thrombolytic agent (see

Para. 4.1.6 below for more details).

4.1.6 – Managing peripheral embolization associated with thrombectomy

If a complication of the thrombectomy treatment occurs, its management may also generate additional codes.

In addition to the complications associated with angioplasty, the major complication of thrombectomy is

peripheral arterial embolization. This may require an embolectomy. The situation as it relates to the upper

and lower extremities is slightly different.

4.1.6.1 - Peripheral arterial embolectomy – upper extremity

In most instances, the upper extremity will be involved in this complication occurs since this is where most

dialysis accesses are located. Embolization symptoms are generally immediate. Treatment of this

complication is necessary; this generally generates a series of codes (Table 4).


10

The procedure will necessarily require an arteriogram (75710) to confirm that an embolus to the artery has

occurred and to define its exact location. Since this code is a diagnostic RS&I code which, in this instance

will be used in association with a therapeutic RS&I code (bundled with the thrombectomy code), it should

have a -XU modifier attached.

The first step in the procedure for embolus removal generally involves selective catheterization of the

artery. If this is a first order branch, the code for this in the upper extremity is 36215. The descriptor for this

code is – selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch,

within a vascular family. The brachial artery should be classified as a first order branch if that is the first artery

entered. In the case of an access fed directly from the radial artery, then this vessel would be the first order

branch. (see para 6.2.2 below).

If the procedure requires passing a catheter more distally into the arterial tree, then this might necessitate a

different code. The code for a second order artery in the upper extremity is 36216. The descriptor for this

code is - selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch,

within a vascular family. Both the radial and ulnar arteries should be considered second order branches if

one is dealing with a brachial artery based access.

The code most appropriate for use for embolectomy of an artery associated with the thrombectomy of a

dialysis access circuit is +37186. The descriptor for this code is - secondary percutaneous transluminal

thrombectomy, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural

pharmacological thrombolytic injections, provided in conjunction with a percutaneous intervention other than

primary mechanical thrombectomy. The +37186 code is designed to cover any method or combination of

methods. This code includes all the work required to remove the embolus regardless of the method

used. It includes both mechanical and pharmacological techniques and any pharmacological agents that

might be used.

The code + 37186 is an add-on code and therefore cannot stand alone. It must be used in conjunction with

another basic code, in this case the code for thrombectomy 36904-6. Additionally, it is a column 2 code to

36904-6 and is mutually exclusive; however, it does allow for the use of a modifier to justify its use. In this

instance the modifier -XU is the one most appropriate for use. Therefore, when used in the context in which


11

we are applying it, the code should be represented as + 37186-XU. The fact that the embolus being treated

is not merely an extension of the dialysis access circuit thrombus and is a separate procedure distinct

from the thrombectomy should be clearly documented in the patient record and in the recorded images.

When an embolus occurs as a complication of a mechanical thrombectomy in the upper extremity, it generally

lodges in the brachial artery, just above the bifurcation. However, at times, it may pass into the radial or ulnar

arteries. For the purpose of coding, the exact location of the embolus is not important. The +37186-XU

should be used regardless of the site of the embolus.

4.1.6.2 - Peripheral Artery Embolectomy – Lower Extremity

As stated above treatment of a peripheral artery embolus following a thrombectomy as it relates to the upper

and lower extremities is slightly different, but only slightly. The arteriogram code 75710, and the

embolectomy code +37186 that should be used are the same regardless of whether the procedure

involves the upper or lower extremity. However, codes that should be used for selective catheterizations,

if these are required are different.

Selective catheterization of a first order artery in the lower extremity is 36245. The descriptor for this code

is - selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery

branch, within a vascular family. If it becomes necessary to selectively catheterize a second order artery, the

appropriate code should be 36246. The descriptor for this code is - selective catheter placement, arterial

system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family.

4.1.6.2.1 – Embolectomy in lower extremity with arterial angioplasty

It should be noted that if an arterial angioplasty has been performed, the Lower Extremity

Revascularization coding system comes into play (see Para 5.4 below). In this instance, any selective

catheterization that is performed would be bundled with the basic procedure code. However, the diagnostic

angiogram would not be bundled and could be coded separately as part of the 36901-3 code that would be

most appropriate for the dialysis access procedure that was performed. It should be noted, however, that

these special rules apply in the lower extremity only if an arterial angioplasty is performed. Otherwise, coding

is the same as in the upper extremity.

4.1.6.3 - Special Situations Relating to Embolectomy

In most cases when a thrombectomy procedure is complicated by the occurrence of an embolus, there is a

single embolus. However, in some cases multiple emboli may be present or the attempts at removal of the

initial embolus results in a fragment breaking off and moving further down the artery to represent a second

embolus. The procedure to remove these clots should be coded as a single embolectomy procedure

using a single +37186 regardless of the number of thrombi that are removed.

4.1.7 – Delayed arterial embolus

There are instances in which an embolus may be delayed, i.e., symptoms appear the following day. The

treatment of this complication constitutes a separate setting. Since the embolectomy code +37186 is an add-


12

on code it cannot stand alone, but must be used in conjunction with another basic code. The case would

generally be approached either by cannulating the dialysis access circuit or by a direct arterial cannulation.

In the former instance, the basic angiogram code 36901 should be used as the primary code. In the case of

an arterial cannulation the codes 36140 and 75710 would be generated (see Para 5.2.1). The arterial

cannulation code 36140 would serve as the primary code in this instance (see example).

Example: a patient develops symptoms of an embolus the day following a thrombectomy. The dialysis access circuit is cannulated

an angiogram is performed. This is followed by selective catheterization of the artery to identify the presence of an embolus. The

embolus is removed successfully. The case should be coded as 36901(dialysis access circuit angiogram), 36215 (selective

catheterization of first order artery), 75710-XU (arteriogram of extremity) and +37186 (embolectomy).

5. ARTERIOVENOUS ACCESS PROCEDURES – ARTERIAL

5.1 - CANNULATION OF BRACHIAL OR RADIAL ARTERY

There are situations in which it is necessary to cannulate either the brachial or the radial artery ipsilateral to

the dialysis access to accomplish the required task. The code for cannulation of the extremity artery is

36140. The descriptor for this code is - introduction of needle or intracatheter; retrograde extremity artery.

This code should be used whether the radial or the brachial artery is cannulated.

Cannulation codes both nonselective cannulation and selective catheterization (see Para 2.1.1) are bundled

with the 36901-6 codes. The direct cannulation of the feeding artery of an access (36140) in order to perform

a procedure presents an instance in which there is an independent nonselective cannulation code for the

procedure, the appropriate coding for the case will depend upon the purpose of the cannulation (see Para

6.2.2.4).

5.2 - ARTERIOGRAM

In most instances, the coding guidelines for an arteriogram in the upper and lower extremity are the same.

An exception to this rule for the lower extremity is described below in Para.5.2.2.

5.2.1 – Basic coding for arteriogram

The code for an arteriogram is 75710. The descriptor for this code is – arteriogram extremity, unilateral,

radiological supervision and interpretation. There should also be a clear medical indication for the study. An

examination of the artery adjacent to the arterial anastomosis is included in the 36901-6 codes. This should

be interpreted as being within approximately 2 cm of the anastomosis. Use of the 75710 code would be

warranted only if you examined a larger segment of the artery. Proper use of 75710 assumes that you

examine that portion of the extremity arteries that is necessary to make a diagnostic evaluation related to

your medical indication.

This arteriogram may be performed by selective catheterization of the artery or by occluding the access

downstream and refluxing radiocontrast into the artery. The technique used to perform the arteriogram


13

does not affect the use of the code. However, the extent of the segment of artery examined is important

regardless of the technique used.

It should be remembered that if 75710 is applied in conjunction with a therapeutic RS&I code, it should have

a -XU modifier attached (see comments on p. xi - Diagnostic RS&I code used in association with a

therapeutic RS&I code).

5.2.2 – Arteriogram performed with arterial angioplasty

Although performing an arterial angioplasty in a thigh access brings the Lower Extremity Revascularization

codes into play, coding of the arteriogram is warranted since diagnostic angiography is not bundled with

the basic code. The exception to this rule is when the intervention is based upon an angiogram that has been

previously performed. In this case, any repeat study should not be coded unless it can be documented that

there has been a change in the patient’s medical condition. This prohibition also includes any follow-up

angiograms performed after an interventional procedure (angioplasty, atherectomy, stent placement,

thrombectomy) since this would be bundled with the basic procedure code.

Coding Tip: If an arteriogram code is used, the procedure note should clearly define the medical indication for the study. If a

selective catheterization is coded, the medical indication for the catheterization should also be detailed.

5.3 - ARTERIAL ANGIOPLASTY - UPPER EXTREMITY

The coding for arterial angioplasty in the upper and lower extremities is somewhat different. The arterial

anastomosis is defined as the surgically created junction of the access and the artery. This, along with

the adjacent approximately 2 cm of feeding artery, is defined as part of the peripheral segment of the

dialysis access circuit. Treatment of a lesion in this region should be coded as 36902.

Lesions within the arterial circulation that are more than approximately 2 cm from the arterial

anastomosis are not considered to be part of the dialysis access circuit. A stenotic arterial lesion that

is treated here is coded as an arterial angioplasty and each named artery with a lesion that is treated, is

coded separately. This would be in addition to any codes that are assigned to lesions within the dialysis

access circuit. If an arterial lesion is continuous with an anastomotic lesion, it should be considered as

part of the anastomosis and covered by the same code used for that structure no matter how extensive it

may be.

The code for an arterial angioplasty in the upper extremity is 37246. The descriptor for the angioplasty code

is – transluminal balloon angioplasty, brachiocephalic trunk or branches, each vessel. This code should be

used for an arterial angioplasty performed anywhere within the entire arterial system of the upper

extremity as defined (not the first 2 cm). When more than one arterial angioplasty is done the code

37247 should be used to indicate the procedures were done on separate structures.


14

5.4 – ARTERIAL ANGIOPLASTY WITH STENT PLACEMENT - UPPER EXTREMITY

If a stent is placed in an artery more than 2 cm removed from the arterial anastomosis, it should be coded

with the code 37236. The descriptor for this code is - transcatheter placement of an intravascular stent(s)

(except lower extremity, cervical carotid, extracranial vertebral are intrathoracic carotid, intracranial, or

coronary), open or percutaneous, including radiological supervision and interpretation and including all

angioplasty within the same vessel, when performed; each additional artery (list separately in addition to the

code for primary procedure). If a stent is placed in a second artery, the code +37237 should be used. This is

an add-on code with 37236 serving as the primary code. These are bundled codes and all aspects of the

procedure are included. A separate code can be used for each individually named artery that is treated.

5.5 - ARTERIAL ANGIOPLASTY - LOWER EXTREMITY

While anastomotic angioplasty is bundled with the 36901-6 code, lesions that are present within the arterial

circulation and more than 2 cm from the anastomosis are coded using the Lower Extremity

Revascularization bundled coding system. These are hierarchal, bundled codes in which the arteries of

the lower extremity are divided into three territories. An arterial lesion that occurs in association with a lower

extremity dialysis access is most frequently in the femoral artery which is coded with 37224. A more proximal

lesion within the iliac group of arteries should be coded with 37220. The descriptors for these codes are -

revascularization, endovascular, open or percutaneous, femoral (or iliac) artery, unilateral, initial vessel; with

transluminal angioplasty. It is possible to code for each individually named artery within the system.

These lower extremity codes are all inclusive except for the diagnostic angiogram. In this situation in which

an arterial angioplasty is required in the lower extremity, the appropriate code from the 36901-6 codes should

be used to cover the work done in the dialysis access. At a minimum, this should be 36901 for cannulation

and an angiogram of the dialysis access. This code should be listed in addition to the arterial angioplasty

code with a modifier to indicate a reduced level of service, 37224-52 and 75710 for the arteriogram. It should

be remembered that if 75710 is applied in conjunction with a therapeutic RS&I code, it should have a -XU

modifier attached.

Coding Tip: Since the appropriate code for this procedure is dependent upon the artery involved, it is important that one name

the artery in the operative note.

5.6 - ARTERIAL ANGIOPLASTY WITH STENT PLACEMENT - LOWER EXTREMITY

In the case of a lower extremity dialysis access, if an angioplasty performed more than 2 cm from the arterial

anastomosis is followed by stent placement it should be coded with the bundled code either 37226 (arteries

within the femoral vascular territory) or 37221 (arteries within the iliac vascular territory). The descriptors for

these codes are - revascularization, endovascular, open or percutaneous, femoral (or iliac) artery, unilateral,

initial vessel; with transluminal stent placement(s), includes angioplasty within same vessel, when performed.

It is possible to code for each individually named artery within the system. These are bundled codes which

include all aspects of the procedure.


15

Note: The Lower Extremity Revascularization coding system includes angioplasty, atherectomy and stent placement. These

codes describe revascularization therapies for occlusive disease and lower extremity (i.e., transluminal angioplasty, atherectomy,

and stent placement) provided in three arterial vascular territories: (1) iliac, (2) femoral/popliteal, and (3) tibial/peroneal. Most of

this system does not impact upon dialysis vascular access. However, these vessels are involved with an access located in the

thigh. These cases may develop problems in the iliac or femoral/popliteal territories; it does affect the way these will need to be

coded. The series of codes 37220 - +37235 are to be used to describe lower extremity endovascular revascularization services

performed for occlusive disease for all vessels of the lower extremity.

6. SECONDARY CODES FOR ARTERIOVENOUS ACCESS PROCEDURES

6.1 – SPECIAL PROCEDURES

In addition to the codes for the basic procedures which have been described, there are codes for other

procedures that play a secondary role in individual case. However, some codes cannot be reported with the

primary 36901-8 codes

6.1.1 - Codes which may not be reported with primary codes 36901 – 3 or 36904 – 6

There are codes which may not be reported separately with the bundled dialysis access circuit intervention

codes 36901 – 36906 (Table 5). The nonselective cannulation code 36148 (cannulation for therapeutic

intervention) has been deleted. The work of any additional cannulation(s) for imaging or intervening on

the dialysis access circuit is included in the bundled dialysis access circuit codes (36901-6). The

code 75791 for angiogram of a dialysis access circuit without cannulation has been deleted. Other codes

that cannot be used are listed in Table 5.

6.1.2 - Codes which may be reported with primary codes 36901 – 3 or 36904 – 6

Several codes may be reported separately if the appropriate elements for reporting are performed.

Ultrasound guidance for cannulation may be necessary to safely and effectively cannulate the access for

evaluation. Ultrasound guidance may be reported separately using code +76937. If a balloon or another

device is used as a target to guide cannulation (punctured with the needle to facilitate cannulation of the

vessel) this is reported with 77002. If a more proximal arterial inflow problem separate from the peri-

anastomotic segment is suspected and additional selective catheterization and imaging must be done for

adequate evaluation, this work is not included in code 36901-6. This includes the codes 36215 (selective

catheterization of first order artery) and 36216 (selective catheterization of second order artery). These are

typically used to perform an upper extremity arteriogram 75710 (unilateral upper extremity arteriogram). The

arteriogram may also be separately reported if there is a medical indication for the study.


16

The codes 36901 – 36903 include cannulation of the dialysis access proper. If another vessel is

cannulated to perform the angiogram of the access, this cannulation should be coded separately.

Cannulation of brachial or radial artery (36140) is an example that might occur in less common clinical

scenarios.

Angioplasty within the upper extremity arterial system separate from the dialysis access is coded separately

with a new bundled code (37246) and additional vessel add on code (+37247). Additionally, the coding of an

arterial angioplasty in the lower extremity is not the same as one in the upper extremity (see Para 5.5.).

6.2 - CANNULATION (CATHETERIZATION) CODES

Cannulation or catheterization (in this context, the terms are used to mean the same) may be either

selective or nonselective. These codes are mutually exclusive. This principle involves both arterial and

venous vessels. In order to code properly, this concept must be mastered.

6.2.1 - Nonselective cannulation

The most frequently performed cannulation is nonselective. The target vessel is entered directly, and the

device used for the cannulation (usually just a needle) is not manipulated further. The target vessel has been

accessed and the procedure is over. Cannulation of brachial or radial artery (36140) is an example of

nonselective cannulation. Nonselective cannulation of the dialysis access circuit is bundled within codes

36901-6 and therefore are not listed separately.

6.2.2 - Selective catheterization

Selective catheterization involves the use of a catheter which is moved, manipulated or guided into a branch

of the vessel, either an artery or a vein, which was originally entered as defined for nonselective cannulation.

This is generally done under fluoroscopic guidance and most often using a guidewire. This involves more

physician work and effort and increases the complication risk to the target vessel. However, it is important to

recognize that this definition refers to the location of the catheter and not the guidewire.

6.2.2.1 Selective catheterization not allowed

Selective catheterization of venous branches of the dialysis access circuit is bundled with 376901. This

means that it cannot be separately coded with the basic 36901-6 group of codes. Basically, only the arterial

selective catheterization codes can be attached to procedures performed in the dialysis access circuit. There

are other situations in which selective catheterization is also not appropriate (Table 6).

Crossing a lesion only for the purpose of positioning an angioplasty balloon does not qualify for

selective catheterization coding. Such a maneuver should be regarded as a reasonable part of that basic

procedure. The same is true for any post-angioplasty angiogram that is performed.


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Any selective catheterization performed to visualize any part of the dialysis access circuit including the

superior and inferior vena cavae is bundled with 36901 and can therefore, not be coded.

Selective catheterization for gaining entry into the dialysis access circuit is bundled with the primary

procedure codes 36901-6. When selective catheterization is used to gain entry to the dialysis access by

initially cannulating the artery, no additional selective catheterization code is warranted (see Table 7).

The first 2 cm of the feeding artery is part of the anastomosis (arterial) and therefore considered to be

part of the dialysis access circuit. Selective catheterization of the arterial inflow (feeding artery) may only be

coded if done for imaging or intervention of the arteries that are not part of the dialysis access circuit.

All selective catheterizations done for imaging or intervening on the dialysis access circuit are included in

36901 – 36906.

The key distinction is the purpose or medical indication for selective catheterization – it is only

separately reported for work done outside of the dialysis access circuit

Example 1: A micropuncture needle was inserted into the fistula, approximately 10 cm from the anastomosis with the needle tip pointing in an up-stream direction. An angiogram was performed, but did not visualize the juxta- anastomotic artery. Because of clinical findings it was felt that this should be selectively catheterized, and a diagnostic angiogram should be performed. After a sheath had been inserted, a guidewire was manipulated across the arterial anastomosis. This was followed by a vascular catheter which was placed across the arterial anastomosis. An angiogram was performed to visualize juxta- anastomotic artery. In this case, a selective catheterization code is not warranted since the documentation indicates that only that portion of the feeding artery which is part of the dialysis access circuit was examined. Example 2: A micropuncture needle was inserted into the fistula, approximately 10 cm from the anastomosis with the needle tip pointing in an up-stream direction. An angiogram was performed, but did not visualize the juxta- anastomotic artery. Because of clinical findings, it was felt that the brachial artery should be examined. After a sheath had been inserted, a guidewire was manipulated across the arterial anastomosis. This was followed by a vascular catheter which was advanced up to the subclavian artery. An angiogram was performed to visualize the entire brachial artery down to the anastomosis of the fistula. In this case, a selective catheterization code is warranted since the documentation indicates that a segment of the brachial artery beyond the juxta- anastomotic portion was examined. In this case 36215 and 75710 should be added to the appropriate 36901-6 code.

Careful documentation is important when using the selective catheterization codes. This should include the

medical necessity for both the procedure to be performed and the use of selective catheterization,

and the documentation of the branching anatomy involved in gaining access to the target vessel.


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These selective codes were originally developed for use based upon cannulation of a central vessel from

which one progressed peripherally. In dealing with dialysis access dysfunction; however, the process is

generally reversed; the progression is generally (although not always) accessing a peripheral vessel and

progressing centrally. The key element in defining selective catheterization is the branching anatomy.

Selective catheterization is advancing the catheter from one vessel into a chosen branch. If the catheter is

passed into a contiguous (continuous), non-branching vessel, rather than a branch, a selective

catheterization code is not warranted. An example of where the code would be inappropriate is going from

radial into the brachial artery. Going from the brachial artery into the radial artery would qualify as

selective catheterization since the radial is a branch of the brachial.

Example 1– A radial-cephalic AVF is cannulated in a retrograde direction. An arteriogram is medically indicated. A vascular

catheter is advanced across the arterial anastomosis into the proximal radial artery. The catheter is then advanced up to the origin

of the subclavian artery. Only a first order selective catheterization would be warranted since the brachial artery and subclavian

artery are contiguous extensions.

Example 2 - The brachial artery is cannulated in order to evaluate a patient with a radial-cephalic AVF. Using a guidewire, a vascular catheter is advanced from the brachial artery into the radial artery and then advanced further across the arterial anastomosis into the AVF. In this instance, entering the radial artery from the brachial artery creates the possibility for a first order selective catheterization code. A possible second order selective catheterization code would be created by advancing the catheter into the AVF. However, the descriptor for the 36901-6 code group states “… including all direct puncture(s) and catheter placement(s).” Therefore, all nonselective and selective cannulations and catheterizations are bundled. The final coding for this case should be only 36901-6 (depending on the primary procedure).

Example 3 - A brachial-cephalic AVF is cannulated in a retrograde direction. An arteriogram is medically indicated because of

hand ischemia. A vascular catheter is advanced across the arterial anastomosis into the brachial artery. The catheter is then

advanced into the radial branch of the brachial artery. In this instance, entering the brachial artery from the AVF would warrant a

first order selective catheterization code. A second order selective catheterization code would be warranted by advancing the

catheter into the radial artery. Only this second order code should be listed.

Selective catheterization codes were originally developed for use based upon cannulation of a central vessel

from which one progressed peripherally. In dealing with dialysis access dysfunction; however, the process is

generally reversed; the progression is generally (although not always) accessing a peripheral vessel and

progressing centrally.

The performance of a selective catheterization requires a double indication. First, there is a

requirement for a medical indication for the procedure that is to be performed. Second, there is an

absolute need for a medical indication for the selective catheterization that is different than imaging

or intervening upon the dialysis access circuit.

Notice that these codes are not attached to an anatomically named vessel. The same vessel could be a

first or second order branch depending on the vessel which was the primary site of the nonselective

cannulation. If the brachial artery is selectively cannulated from a radial-cephalic fistula, it would be a second

order branch. If the same vessel was catheterized from a brachial-cephalic graft, it would be a first order

branch (it is the first artery that you come to from that site). Likewise, the radial artery would be a second


19

order branch if reached by first passing through the brachial, but would be a first order branch if it is the artery

attached to the access as is the case with a radial-cephalic fistula. The code used in each instance must

indicate the order of the branch rather than being specific for an anatomical name.

Coding Tip: The cannulation (catheterization) codes whether nonselective or selective as discussed below includes: "necessary

local anesthesia, introduction of needles or catheter, injection of contrast media with or without automatic power injection, and/or

necessary pre- and post-injection care specifically related to the injection procedure".

6.2.2.2 – Selective catheterization - venous

Each member of the 36901-6 code group bundles an angiogram of the access with a nonselective

cannulation. These codes also describe all needle and selective catheter manipulation within the

access circuit and any venous branches (accessory veins) to perform a diagnostic radiological study to

evaluate the dialysis vascular access. Therefore, neither nonselective cannulation nor venous selective

catheterization may be coded separately. Advancement of a catheter through the arterial anastomosis to

visualize the anastomosis and adjacent approximately 2 cm of feeding artery is also considered

integral to the work of 36901–6 and is not coded separately.

Figure 3 – Catheterization sequence for arterial catheterizations. The codes 36901-6 are bundled codes which includes nonselective cannulation. The appropriate selective cannulation code should be used in addition to the appropriate bundled code from this group.

6.2.2.3 – Selective Catheterization – Upper Extremity Arterial

The most common scenario in which selective catheterization is warranted is when unique pathology

presented by an individual case requires that an artery be selectively catheterized to facilitate the

performance of an arteriogram and the appropriate treatment of the case. In this instance either the

code 36215 or 36216 would be warranted depending upon the specific sequence of the target artery entered

(Figure 3). The descriptor for 36215 is – selective catheter placement, arterial system, each first order thoracic

or brachiocephalic branch, within a vascular family. For the code 36216, the descriptor is - selective catheter

placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family

(Figure 3).


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It is important to note that the advancement of the catheter tip through the arterial anastomosis to visualize

only the anastomosis and first 2 cm of the feeding artery is considered integral to the work of 36901–6 and

not warrant an additional code. Therefore, if one is to code a selective catheterization procedure based upon

the catheterization of the feeding artery, one must visualize (and have an indication to do so) more than just

the anastomosis an adjacent 2 cm of the feeding artery.

In some instances, a procedure performed on a dialysis access is initiated by first cannulating the feeding

artery. This may be done antegrade via the brachial artery or retrograde via the radial (there are other

possibilities). In order to cross the arterial anastomosis and enter the access, selective catheterization of the

access may be required. In this instance the access would be the first order vessel. Doing this raises the

question of using a selective catheterization code; however, the descriptor for the 36901- 6 code group states

“... including all direct puncture(s) and catheter placement(s).” Therefore, all nonselective and selective

cannulations and catheterization necessary for the basic procedure are bundled in the 36901-6 codes. In this

instance, the listing of a separate nonselective cannulation or selective catheterization code would

not be warranted. The arteriogram code is warranted if the requirements for a diagnostic arteriogram were

met, code 75710.

Coding tip: If selective catheterization is being used to gain entry into the dialysis access itself, the code for this procedure is bundled with 36901-6. If it is being used to advance from the dialysis access which has been cannulated into either a qualifying arterial or venous structure, the selective catheterization code should be added to the appropriate 36901-6 code.

Example 1: The brachial artery was cannulated. In order to enter the fistula, the guidewire was passed down the radial artery and

a guiding catheter was used to selectively catheterize the arterial anastomosis. Once the catheter was passed into the access an

angiogram was performed to visualize the access and its drainage. The radial artery should be classified as the second order

artery and the code 36216 would be warranted (second order because one had to pass through the radial artery first, then the

fistula); however, all nonselective cannulation and selective catheterization of the dialysis access circuit is bundled in the

36901-6 code group. Therefore, these codes cannot be used. The final coding for this case should be only 36901-6 (depending on

the primary procedure).

Example 2: A radiocephalic fistula was cannulated retrograde to perform complete upper extremity arteriogram to evaluate steal

symptoms. Selective catheterization using a guidewire and catheter was performed to reach the proximal radial artery. The wire

and catheter were then further manipulated into brachial, axillary and subclavian arteries to allow contrast injection for the

arteriogram. The radial artery should be classified as first order artery and code 36215 should be used. However, higher level

second or third order artery codes should not be used because the additional arteries passed are direct extensions and not

branches from the radial artery. The final coding for this case should be 36901-6 (depending on the primary procedure) and 36215

in addition to the arteriogram code 75710.

6.2.2.3.1 - Exception for the lower extremity

The lower extremity requires that an exception to the use of nonselective cannulation codes be applied. When

performing an arterial angioplasty in the artery proximal to the access as defined, the Lower Extremity

Revascularization coding system is used. These lower extremity endovascular revascularization codes

are all inclusive (except for diagnostic angiography). The basic cannulation and any selective

catheterization is bundled with the basic procedure code.


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6.2.2.4 Dropping nonselective code when selective code is used

The basic rule for the cannulation codes is that a nonselective code is replaced (dropped) each time a

selective one is used. However, because 36901-6 are bundled codes, the nonselective cannulation cannot

be dropped when a selective catheterization is performed. Both the selective catheterization code and the

bundled dialysis access code may be reported when selective catheterization is indicated and performed

according to the rules outlined above.

The direct cannulation of the feeding artery of an access (36140) presents an instance in which there is an

independent nonselective cannulation code for the procedure, the appropriate coding for the case will depend

upon the purpose of the cannulation (Table 7):

• If the arterial cannulation (36140) was for the purpose of gaining entry into the dialysis access, then

neither a nonselective cannulation nor a selective catheterization code would be warranted

since they are bundled in the basic 36901-6 code group.

• If the arterial cannulation (36140) was for a purpose that involved a structure independent of the

dialysis access itself, then this nonselective code should be dropped in favor of a higher level

selective catheterization code (36215, 36216) In these instances, only the highest-level code which

is appropriate should be listed, all others should be dropped (see Example 1 below).

Example 1: The patient is being evaluated for dialysis access steal syndrome. A Doppler ultrasound study was performed which

shows evidence of a stenotic lesion in the mid-radial artery. It was felt that the best approach to this lesion involved cannulating

the brachial artery and selectively catheterizing the radial in order to perform the angioplasty on the lesion. This procedure was

conducted in this matter was successful. The final coding for this case should be 36140 for the cannulation of the brachial artery.

This nonselective code should be dropped in favor of 36215, selective catheterization of a 1st order artery, in addition to the code

for an arterial angioplasty (37246) and unilateral extremity arteriogram (75710).


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6.3 - Aids for difficult cannulation

In some instances, the cannulation of the dialysis access circuit is very difficult to accomplish. This is

particularly true in the case of new or failing AVF. Some type of aid is required to accomplish the necessary

task and complete the required treatment. Two aids that have been used effectively are ultrasound guidance

and the use of an angioplasty balloon passed from another site to use as a target (balloon-guidewire

entrapment). Both are codable events.

6.3.1 - Ultrasound guidance

Ultrasound guidance for the cannulation procedure is not included in 36901–6. The appropriate code

for this ultrasound guided access cannulation procedure is +76937. The descriptor for this code is –

ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites,

documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle

entry, with permanent recording and reporting (List separately in addition to code for primary procedure). This

code was created to report the work performed when ultrasound imaging is used in conjunction with another

surgical or imaging surface where the modality of ultrasound imaging is not inherent to the primary

procedure. As the descriptor indicates, this requires image documentation for the medical record. It should

be noted that, as the descriptor indicates, evaluation of potential access sites documentation of selected

vessel patency and con current real-time ultrasound visualization of the needle entry is a requirement. If

these are not done along with creating a permanent record (image) and reporting, the use of the +76937

code is not permissible.

Coding Tip: In instances in which image documentation is required, it is recommended that the fact that an image was obtained

be documented in the procedure note in addition to inserting an image into the medical record. This will assure that if the record is

reviewed at a later date the fact that an image was obtained and saved will be documented.

6.3.2 - Target device

In some cases, it is possible to insert a device such as an angioplasty balloon at another site and pass it

to the site deemed optimum for cannulation and use it as a target. This cannulation is generally done with

fluoroscopic guidance for the cannulation needle placement. The code for this procedure is 77002. The

descriptor for this code is - Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection,

localization device). This code is a column 2 code to 36901–6. It can be used with these codes but does

require a modifier. In the instance described here, an -XU modifier would be appropriate. The code +77001

cannot be used in conjunction with 77002.

6.4 Sedation

Pain management through effective sedation/analgesia is an important aspect of the conduct of interventional

procedures dealing with dialysis vascular access. The codes 99152 and 99153 can be used for moderate

sedation services provided either by the physician performing the procedure. The code 99152 is for the initial

15 minutes of sedation. Each additional 15 minutes of sedation warrants the code 99153. This latter code

may be used multiple times and should be listed in addition to the code for the primary service, 99152. It

should be noted that that in order to qualify for the use of these codes, the sedation service must be provided


23

by the same physician (or other qualified health care professional) performing the diagnostic or

therapeutic service that the sedation supports.

6.4.1 Initial 15 minutes

The descriptor for 99152 is - Moderate sedation services provided by the same physician or other qualified

health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring

the presence of an independent trained observer to assist in the monitoring of the patient’s level of

consciousness and physiological status; initial 15 minutes of intra-service time, patient age 5 years or older.

6.4.2 Each additional 15 minutes

The descriptor for 99153 is - Moderate sedation services provided by the same physician or other qualified

health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring

the presence of an independent trained observer to assist in the monitoring of the patient’s level of

consciousness and physiological status; each additional 15 minutes of intra-service time (List separately in

addition to code for primary service). Multiple 99153 codes can be used when warranted based upon total

sedation time (Table 8). In instances in which more than one 99153 codes have been used, the second usage

and all subsequent uses should be reported in units (X2, X3).

6.4.3 – Sedation Medications

Most of the interventional procedures performed for dialysis access maintenance have the potential for being

painful and therefore require the administration of medications for sedation/analgesia. In order to obtain

reimbursement for these drugs HCPCS (Healthcare Common Procedure Coding System) level II J-codes

must be used (CPT codes are level I HCPCS codes). The J-codes are used for the coding of drugs that are

not orally administered. These codes are represented by 6 alphanumeric characters. In this case, the first

character is a “J” followed by five numbers. These codes are specific for the drug and also specify a dosage


24

(Table 9). If the quantity of medication administered exceeds the dosage specified, multiple uses of the J-

code are warranted. Subsequent uses of the code should be reported in units

6.5 – EKG Monitoring

Although there is a code for EKG interpretation, 93040, that could be used for the monitoring performed

during an interventional procedure. EKG interpretation is bundled with the basic procedure for which

monitoring is being performed and should not be separately coded.

7. ULTRASOUND OF DIALYSIS ACCESS CIRCUIT 7.1 – ULTRASOUND EVALUATION OF DIAYSIS ACCESS

There are instances in which the evaluation of the dialysis access circuit using duplex ultrasound is medically

indicated. The code for this study is 93990. The descriptor for this code is – duplex scan of hemodialysis

access (including arterial inflow, body of access and venous outflow). It is important to note that this must

include all components of the access. This must include B-mode, spectral Doppler and color Doppler as

appropriate to produce a complete exam for the individual access studied. This should also include evaluation

of the artery, arterial inflow and venous outflow. All diagnostic ultrasound examinations require

permanently recorded images with measurements, when such measurements are clinically indicated.

Coding Tip 1: In instances in which image documentation is required, it is recommended that the fact that an image was obtained



Coding Tip 2: In doing an ultrasound evaluation of a dialysis vascular access and applying the code 93990, be aware of ultrasound

definitions.

Duplex ultrasound – this is a form of ultrasound that incorporates two elements (thus the term duplex) – traditional 2D (B mode)

ultrasound and Doppler ultrasound. This allows for visualization of both anatomy and flow dynamics.

2D Ultrasound - basic ultrasound, images of anatomy, 2 dimensional, gray scale images.

Doppler ultrasound – this form of ultrasound employs the Doppler effect to assess whether blood is moving towards or away from

the ultrasound probe, and its relative velocity. By calculating the frequency shift of a sample volume, its speed and direction can


25

be determined and visualized. The Doppler information is displayed graphically using spectral Doppler, or as an image using color

Doppler.

Spectral Doppler ultrasound - A form of Doppler ultrasound image display in which the spectrum of flow velocities is represented

graphically on the Y-axis and time on the X-axis.

Color flow Doppler ultrasound - A form of pulse wave Doppler in which the energy of the returning echoes is displayed as an

assigned color; by convention echoes representing flow towards the transducer are seen as shades of red, and those representing

flow away from the transducer are seen as shades of blue. The color display is usually superimposed on the B-mode image, thus

allowing simultaneous visualization of anatomy and flow dynamics.

Example 1 - A patient with a three-month-old AVF is referred to the access center for evaluation because of difficulty with cannulation. The decision is made to perform an ultrasound study on the AVF. An example of a report that meet the qualifications for coding as 93990 is as follows: The patient has a left form radial- cephalic AVF. The cannulation zone of the AVF, the draining veins within the arm and the feeding artery were examined using 2D ultrasound, Doppler ultrasound and color flow Doppler ultrasound. The radial artery is 2.5 mm in diameter, anastomosis appears normal, the cannulation zone of the AVF ranges from 6 to 7 mm in diameter and is 5 mm in depth, the draining veins in the upper arm is 8 mm in diameter. No areas of stenosis were detected. Blood flow in the brachial artery was

780 mL per minute.

7.1.1 Imaging by More Than One Modality

Imaging of the same vascular structure by more than one modality on the 8.1.1 same day should not be

coded under ordinary circumstances. (See Para. 8.3.1.1 below)

7.2 Use of Ultrasound to Assist Dialysis Access Circuit Cannulation

In some instances, the cannulation of the dialysis access circuit is very difficult to accomplish. This is

particularly true in the case of new or failing AVF. Ultrasound guidance for the cannulation procedure may be

required. This is not included in 36901-6. The appropriate code for this ultrasound guided access cannulation

procedure is +76937. The descriptor for this code is – ultrasound guidance for vascular access requiring

ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent

realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List

separately in addition to code for primary procedure). This should be listed in addition to 36901-6. The code

+76937 is an add-on code and must be used in conjunction with another basic code, in this case 36901-

6. It is important that the components of the descriptor for ultrasound guidance be clearly documented in the

patient record and in the recorded images. As the descriptor indicates this requires image documentation

for the medical record.




8. VASCULAR MAPPING


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8.1 VASCULAR MAPPING

Vascular mapping should be considered in the evaluation of a patient for the placement of a dialysis vascular

access. The goal here is to identify vascular anatomy that would be conducive to the creation of the best

possible access for that patient; generally, this means an arteriovenous fistula. How this procedure is coded

depends upon the patient’s situation related to previous access placement (Table 10).

8.1.1 Vascular Mapping – No Prior Access If the patient has not had a previous fistula or graft, the temporary code G0365 should be used. The

descriptor for this code is - mapping of vessel for hemodialysis access (services for preoperative vessel

mapping prior to creation of hemodialysis access using an autogenous hemodialysis conduit, including

arterial inflow and venous outflow). In order to qualify for this code, imaging can be done using any

technique or combination of techniques. It should be noted that the descriptor for this code specifies that

both the venous and arterial anatomy must be evaluated. If only the veins are imaged, a - 52 modifier

should be attached to the code to indicate a reduced level of service. The G0365 code is for one extremity

only, if both upper extremities are examined the code should be listed a second time with a – XS modifier

to indicate a separate distinct service on a separate structure (separate location). It is important to note that

the use of this code is restricted to a patient that has not had a prior dialysis access graft or fistula.

Additionally, it can only be used two times per year.

Vascular mapping may be done using ultrasound, angiography or a combination of both. The code G0365

covers all of these techniques. However, this is a radiological code; it does not preclude the use of surgical


27

codes that might be warranted based upon the type of procedure performed. If, for example, the vein

mapping portion of the study is performed by angiography, the code 36005 (cannulation of vein and injection

of contrast) may be applied. If mapping is performed on both extremities, angiography should be coded as

36005-50 in compliance with the bilateral surgery (BILT SURG) requirements.

8.1.2 Vascular Mapping – Prior Access In the case of a patient who has had a prior arteriovenous dialysis access (graft or fistula), coding for

vascular mapping involves the use of a group of codes. If done radiographically, this procedure would involve

the use of codes for cannulation of a vein, the injection of contrast and the performance of a venogram. If

done by ultrasound, the codes would be those for ultrasound of the artery and vein of the extremity. If a

combination of both is utilized for the evaluation, then an appropriate combination of codes would be

warranted. The codes that should be used are shown in Table 8.

8.2 ANGIOGRAPHIC STUDY

8.2.1 Cannulation and Injection of Contrast

The code for this procedure is 36005. The descriptor for this code is - injection procedure for contrast

venography (including introduction of needle or intracatheter). If the study is bilateral, then the modifier -50

for bilateral should be applied. This code should not be used at any time when a fistula or graft is cannulated.

Its use is restricted to non-access vein cannulation as with the performance of a venogram.

Coding Tip: Document the fact that more than one site is involved, clearly document each site.

8.2.2 Venogram

There are two possible codes that could be used. The choice depends upon whether the venous mapping

involves only one or both arms. The code for a single arm is 75820. The descriptor for this is – venography,

extremity, unilateral, radiological supervision and interpretation. This code includes all of the veins up to but

not including the superior vena cava (unlike the case with an angiogram of the dialysis access circuit). If the

study is bilateral then the code 75822 should be used. The descriptor for this code is - venography, extremity,

bilateral, radiological supervision and interpretation.

8.2.3 Superior Vena Cava Angiogram

The code for study of the superior vena cava is 75827. The descriptor for this is - venography caval, superior,

with serialography, radiological supervision and interpretation. It should be noted that according to the

descriptor, the 75827 code is for the superior vena cava and not for central veins in general. If the 75827

code is used, the medical indication for the procedure should be clearly stated.

Coding Tip: If a superior vena cava angiogram is coded, one should be sure that that vascular structure was clearly

demonstrated in detail. It should be a complete study. Additionally, the medical indication for a complete study should be clearly

documented.


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8.3 ULTRASOUND STUDY

8.3.1 Ultrasound Study of Artery

The codes for performing ultrasound studies on the artery are 93930 and 93931. The choice of appropriate

code depends on whether it is a unilateral or bilateral study. The code 93930 is for the bilateral study. Its

descriptor is – duplex scan of the upper extremity arteries or arterial bypass grafts; complete bilateral study.

The code for a unilateral study is – 93931. The descriptor for this code is – duplex scan of the upper extremity

arteries or arterial bypass grafts; unilateral or limited study. These codes would include all ultrasound

evaluation performed on the artery or arteries during the course of the study.

8.3.1.1 Multiple imaging modalities on the same day

Unless documentation is provided supporting the necessity of more than one study, one may only code

either a Doppler flow study or an arteriogram, but not both. An example of when both studies may be

clinically necessary is when a Doppler flow study is performed and demonstrates reduced flow (blood flow

rate less than 800cc/min or a decreased flow of 25% or greater from previous study) and the physician

requires an angiogram to further define the extent of the problem. In this instance it is very important that the

patient’s medical record provide documentation supporting the need for more than one imaging study.

Medicare states that it expects this to be an uncommon occurrence.

8.3.2 Ultrasound Study of Vein

The codes for performing ultrasound studies on the vein are 93970 and 93971. The choice of appropriate

code depends on whether it is a unilateral or bilateral study. The code 93970 is for the bilateral study.

Its descriptor is – duplex scan of the upper extremity veins including compression and other maneuvers;

complete bilateral study. The code for a unilateral study is 93971. The descriptor for this code is – duplex

scan of the upper extremity veins including compression and other maneuvers; unilateral or limited study.

These codes would include all ultrasound evaluation performed on the veins during the course of the study.

It is important to note that imaging of a vessel by only one modality can be coded at a single session. If

both an ultrasound study and an angiogram are performed, only one can be coded. Since the angiographic

study is the higher order study of the two, it should be the one generally chosen for assigning a code. Coding Tip: In instances in which image documentation is required, it is recommended that the fact that an image was obtained



9. ARTERIOVENOUS FISTULA - TREATMENT OF ACCESSORY VEIN

9.1 COMMON CODES

The treatment of accessory vein may be done either through ligation or the placement of an embolization

coil. The set of codes that should be used for the procedure would depend upon which modality was

utilized (Table 11).


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9.1.1 Angiogram

The basic dialysis access circuit angiogram code, 36901, should be utilized regardless of the modality being

applied to the accessory vein

9.2 Vein Ligation

The code that is recommended for this procedure is 37607. The descriptor for this code is - ligation or banding

of angioaccess arteriovenous fistula. Additionally, this code also includes the completion angiogram. The

37607 code should only be used once, regardless of the number of vessels ligated or the method of ligation.

9.3 Embolization coil

The procedure involved with the insertion of an embolization call generally includes selected catheterization

as well as the actual placement of the coil.

9.3.1 Selective catheterization

Treatment of an accessory vein generally involves the selective catheterization of the target side branch.

However, selective catheterization is included in the diagnostic angiogram code 36901 so is not separately

reported.

9.3.2 Insertion of Embolization Coil

The code for the insertion of an embolization coil is +36909. The descriptor for this code is – 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. This is an add-on code and must be used with a primary code. The primary code for such a

case would be the appropriate code selected from 36901-3. If the only procedure performed is the

embolization coil, +36909 should be used with 36901, the code for an angiogram of the dialysis access circuit

The code +36909 can be used only once regardless of the number of vessels into which coils are placed.).


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Example - A patient with a newly placed AVF that has failed to mature after 10 weeks is found to have two separate significant

accessory veins and no other explanation for the failure of maturation. Both veins are selectively catheterized, and an embolization

coil is placed in each. In addition to selective catheterization (X2), the coding for this case would reflect only a single code for a

venous coil placement. The case should be coded with 36901 and +36909. No post procedure angiogram should be coded since

this is bundled with the basic procedure.

9.3.3 Management of Complications – Use of Endovascular Snare

Working with embolization coils, there are times when the placement is not as planned, and the coil needs

to be removed. To accomplish this, an endovascular snare may be used. The code for this procedure is

37197. The descriptor for this code is - transcatheter retrieval, percutaneous, of intravascular foreign body

(e.g., fractured venous or arterial catheter), includes radiological supervision and interpretation, and imaging

guidance (ultrasound or fluoroscopy), when performed.

10. TREATMENT OF HAND ISCHEMIA

10.1 HAND ISCHEMIA

Hand ischemia related to dialysis associated steal syndrome (DASS) is a particularly serious problem

associated with dialysis vascular access. This complication can occur with either a graft or an AVF; however,

it is more commonly seen with the latter. Some of these cases are amendable to treatment by interventional

means. Much of the coding of the case uses codes that have already been discussed. There are two types

DASS that may be treated (Table 12), that associated with a high flow brachial artery based access and that

associated with a radial artery based access. In the former, balloon assisted banding of the access has been

used (Figure 4), in the latter distal radial artery embolization (a variant of DRAL or distal radial artery ligation)

has been advocated (Figure 4).


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10.1.1 Balloon Assisted Banding

Ultrasound of the access may be medically indicated to assist in making the diagnosis. Additionally, the

procedure requires an evaluation of access flow to determine if this procedure is appropriate for the case.

The code for this study is 93990. The descriptor for this code is – duplex scan of hemodialysis access

(including arterial inflow, body of access and venous outflow). However, in most cases, the code should not

be used because the overall procedure would also require imaging of the access by angiography and

one cannot code for both modalities

Figure 4 – Treatment of DASS – A. distal radial artery embolization (arrow – coil), B. balloon assisted banding (arrow – point of banding)

In addition to the basic angiogram code, 36901 an arteriogram will generally be required, this will entail

the 75710 code to confirm that stenosis of the proximal artery is not present and to evaluate the distal flow

before and after the banding. The banding procedure itself should be coded with the code 37607. The

descriptor for this code is – ligation or banding of angioaccess arteriovenous fistula. As is the case for all of

the surgical procedure (30000 series) codes, the post procedure angiogram is bundled with the basic code.

10.1.2 Distal Radial Artery Embolization

As with balloon assisted banding, ultrasound of the access may be used to assist with the diagnosis.

Although this raises the possibility of using the 93990 code for duplex scan of the access, the use of the code

would be obviated by the fact that an angiogram of the access would also be required during the procedure

and coding for imaging using two modalities is not permitted.

The basic angiogram of the access code 36901 should be applied. An arteriogram performed to rule out

stenosis of the proximal artery and to assure that the palmar arch is intact would create the need for the

75710 arteriogram of the extremity code. However, in this instance it should have a -XU modifier attached


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because this code is a diagnostic RS&I code which, in this instance will be used in association with a

therapeutic RS&I code for coil placement.

Although not a certainty in all cases, selective cannulation of a first order artery (the radial artery) may be

required. In this instance the code 36215 would be warranted. The descriptor for 36215 is – selective catheter

placement, arterial system, each first order thoracic or brachiocephalic branch, within a vascular family. Both

the selective catheterization code and the bundled dialysis access circuit code may be reported when

selective catheterization is indicated

The code for the insertion of an embolization coil is 37242. The descriptor for this code is - vascular

embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road

mapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or

tumor (e.g., congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous

fistulas, aneurysms, pseudoaneurysms).

As was the case with venous placement of a coil, this code bundles the RS&I code and the follow up

angiogram. Therefore, cannot be separately reported. Additionally, the code 37242 can be used only once

regardless of the number of vessels into which coils are placed. The initial cannulation, selective

catheterization of vessels and the initial diagnostic angiogram are not included and when performed

warrant separate codes.

11. TUNNELED CATHETER PROCEDURES

11.1 PRIMARY CODES

As with the other procedures already discussed, the insertion of a tunneled dialysis catheter generates a

group of codes (Table 13). There are several primary codes that are used in every case. Additionally, there

are secondary codes that may occasionally be used, if the need arises.

11.1.1 Insertion of Tunneled Catheter

The code used for the actual catheter insertion is 36558. The descriptor for this code is – insertion of tunneled

centrally inserted central venous catheter, without subcutaneous port or pump. Over 5 years of age. This

code is for the instance in which a single tunneled catheter is inserted. If two structurally separate

catheters are inserted into two separate venous sites, the appropriate code would be 36565. The descriptor

for this code is - insertion of tunneled centrally inserted central venous access device, requiring two catheters

via two separate venous access sites, without subcutaneous port or pump. The descriptor indicates that if

36565 is to be used, the two catheters must be inserted via separate access sites. A dual catheter

inserted through a single venous access site would not qualify.

Coding Tip: Clearly document the fact that two catheters were inserted at separate venous access sites. This refers to dual

catheters such as the Tesio catheter. If the wrong size catheter was inserted, removed and replaced with the correct size, it should

still be coded as a single catheter.


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11.1.2 Ultrasound Guidance

The code for ultrasound guided cannulation when inserting a tunneled catheter is +76937. The descriptor for

this code is - ultrasound guidance for vascular access requiring ultrasound evaluation of potential access

sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular

needle entry, with permanent recording and reporting. As indicated in the descriptor, use of this code

requires that an image be recorded and made part of the permanent record. Additionally, the record

should include a documented narrative of the localization process for which the guidance is utilized.

This code should not be used in cases where the vein is only examined by ultrasound and the

cannulation is not actually ultrasound guided (real-time). As the descriptor states this requires concurrent

real-time ultrasound visualization of vascular needle entry. This is an add-on code and requires that the

primary procedure also be listed, in this case that would be 36558 as described below.




11.1.3 Fluoroscopic Guidance

The code for fluoroscopic guidance used in connection with the placement of a central venous device is

+77001. The descriptor for this code is - fluoroscopic guidance for central venous access device placement,

replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and

catheter manipulation, any necessary contrast injections through access site or catheter with related

venography radiologic supervision and interpretation, and radiologic documentation of final catheter position).

This code also includes any angiographic study that might be performed in conjunction with the

catheter placement. It is possible to have an angiographic study qualify as a separate procedure if it is

done by selective catheterization or if it is done from a separate access site. In such an instance, a -

XU modifier should be attached to the code to indicate that it is a separate procedure. The code +77001 is


34

an add-on code and requires that the primary procedure also be listed, which should be 36558 as described

below. The code +77001 cannot be used with 77002.

It should be remembered that if 77001 is applied in conjunction with a therapeutic RS&I code (see comments

on p. xi), it should have a -XU modifier attached.

Coding Tip: This code includes the injection of radiocontrast, therefore, codes for angiography of the central veins or superior

vena cava should not be used with it unless they qualify as a separate procedure. If this is the case, then the code should be used

with a -XU modifier. This applies to all catheter related procedures where fluoroscopic guidance is used.

11.1.3.1 Aid for difficult cannulation - using a target device

In some instances, the internal jugular vein cannot be cannulated directly. In some of these cases, it is

possible to insert a device such as an angioplasty balloon or a snare at another site and pass it to the

site deemed optimum for catheter insertion and use it as a target for cannulation. This cannulation is generally

done with fluoroscopic guidance for the cannulation needle placement. The recommended code for this

procedure is 77002. The descriptor for this code is - fluoroscopic guidance for needle placement (e.g., biopsy,

aspiration, injection, localization device). This code also should also be considered to include any necessary

contrast injections through access site or catheter with related venography radiologic supervision and

interpretation, and radiographic documentation of final catheter position.

The code 77002 is not an add-on code. It is however, a column 2 code to 36558 (catheter insertion). It can

be used with that code but does require a modifier. In the instance described here, a -XU modifier would be

appropriate. It is a column 1 code to +77001 and the two are mutually exclusive (can’t be used together).

11.2 SECONDARY CODES

There are times when the central veins are stenotic and require angioplasty before the tunneled catheter can

be inserted. These additional secondary procedures generate additional codes. These are the same codes

that were discussed above. They will be listed again here in order to point out unique aspects.

11.2.1 Venous Angioplasty

At times when a tunneled catheter is being placed, significant venous stenosis is encountered and

complicates the insertion. If a significant stenosis is present, then it should be dilated. In this instance the

appropriate codes would need to be applied. Since this central venous angioplasty is not done via the

dialysis access circuit, the code that is used should be 37248. The descriptor for this code is – transluminal

balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiologic

interpretation necessary to perform the angioplasty within the same vein, initial vein. As stated, this code

includes all aspects of the procedure including the radiological S&I (see Para 3.1.1.1).

Coding Tip: If a venous angioplasty is performed, clearly document the vessel involved and the degree of stenosis as you would

any other time this code is applied.


35

11.2.2 Aborted Cannulation Site

In an occasional instance, after cannulation of the vein for the placement of a tunneled catheter, difficulty is

encountered in passing the guidewire. If, after examining the vein angiographically, it is decided to abandon

that site and move to the opposite side, additional codes may be warranted to account for the work that was

done. The code + 77001 should be used only for the site that is actually used to insert the catheter.

However, the failed attempt represents a separate venous access site and therefore meets the definition

of a separate procedure. Unfortunately, there is no code specifically for this contingency. The code 36410

is the best choice for use in this situation. The descriptor for this code is - venipuncture, age 3 years or

older, necessitating physician's skill (separate procedure), for diagnostic or therapeutic purposes (not to be

used for routine venipuncture). This code should be used if the procedure consisted of only a venipuncture.

If radiocontrast is injected in addition to the venipuncture, then the code 36005 would be warranted.

This code should be used instead of the cannulation code since it bundles both the cannulation and the

radiocontrast injection. The descriptor for this code is - injection procedure for contrast venography (including

introduction of needle or intracatheter).

As with the site actually used for the catheter insertion, an aborted site generally involves ultrasound guidance

for cannulation and angiography. These also require different coding. The recommended code for

ultrasound guided cannulation of an aborted site is +76937. The descriptor for this code is – ultrasound

guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of

selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with

permanent recording and reporting (List separately in addition to code for primary procedure).

For the aborted site, the coding of the angiography is dependent upon the specific vein that is involved.

The vein most often examined is the internal jugular vein. If this is the case and an angiogram of that vein is

performed, then the code 75860 would be warranted. The descriptor for this code is - venography, venous

sinus (e.g., petrosal and inferior sagittal) or jugular, catheter, radiological supervision and interpretation. If

additional vessels were visualized, then additional codes might be warranted. When the code 75860 is used

with 36410, it is a column 1 code and 36410 is a column 2. In this instance, while the two can be used

together, the column 2 code, 36410, would require a modifier. In this instance, a -XU modifier would be

appropriate. The medical necessity for these procedures should be clearly documented in the patient record

and in the recorded images.

11.3 EVALUATION OF EXISTING TUNNELED CATHETER

There are instances in which the evaluation of an existing tunneled catheter using fluoroscopy with

radiocontrast injection is medically indicated. The code for this is 36598. The descriptor for this code is --

contrast injection(s) for radiologic evaluation of existing central venous access device, including fluoroscopy,

image documentation and report. It is important to note that this requires image documentation. The code

36598 is a column 2 code to several codes that might be used in conjunction with dialysis catheter

management procedures. It is mutually exclusive with each of them. This means that they cannot be

used together (Table 14).


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11.4 TUNNELED CATHETER REPAIR

Some catheters are made with a replaceable hub. When it becomes damaged, repair of the hub may allow

for the salvage of the catheter. The code for catheter repair is 36575. The descriptor for the code is - repair

of tunneled or non-tunneled central venous access catheter, without subcutaneous port or pump.

11.5 TUNNELED CATHETER REMOVAL

With most catheters, this is a rather simple procedure providing the catheter was properly place. Catheter

removal is performed under two circumstances. First, the catheter is no longer needed; it is being

removed, not to be immediately replaced. Second, its need is continuing, but it must be exchanged with a

new catheter. The coding for the simple removal would be as follows.

11.5.1 Tunneled Catheter Removal (Not Replaced)

The code for catheter removal is 36589. The descriptor for this code is – removal of tunneled central venous

catheter, without subcutaneous port or pump. If the case involves a twin catheter and both are removed, then

the code 36589 should be used twice with an -XU modifier attached to the second usage. If the catheter is

to be replaced, then the use of this removal code would depend on whether it is to be replaced at the same

venous entry site or a new one as described below.

11.5.2 Tunneled Catheter Exchange

The key factor in coding of a catheter exchange (or replacement) is what happens at the original

venous entry site. If the old entry site is also used for the new catheter, it is classified and coded as an

exchange. This is true even if a new tunnel and exit site were created. If a new venous entry site is

used for the new catheter, abandoning the old site, it is classified as a removal and new catheter

insertion. This is true even if it is on the same side.

11.5.2.1 Same venous entry site

If the old catheter is removed and replaced at the same site such as replacement over a guidewire, it should

be coded as a catheter exchange (Table 14). The code for this is 36581. The descriptor for this code is -

replacement, complete, of a tunneled centrally inserted central venous catheter, without subcutaneous port

or pump through the same venous access.


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11.5.2.1.1 - At non-tunneled catheter site

There are times when a patient is referred for the purposes of converting a non-tunneled catheter to a

tunneled catheter. If the cannulation site is clean and it is in an optimum position, this can be done by

exchanging the catheter over a guidewire and creating a tunnel an exit site for the new catheter. This should

be coded as a catheter insertion. The code for this is 36558 (Table 15).

11.5.2.1.2 – By “wiring-the-tunnel”

Occasionally, a tunneled catheter will be inadvertently removed. Frequently, a new catheter can be inserted

at the old catheter site by introducing a guidewire through the old exit site and advancing it up into the central

veins. The new catheter can then be inserted through the old exit site and tunnel. When this procedure is

done it should be coded as a catheter exchange. The code for this is 36581.

11.5.2.2 New venous access site

If the new catheter is placed at a new venous access site after the old one has been removed, the case

should not be classified as an exchange. In this instance, two codes should be used. The catheter removal

code, 36589, should be used for the removal and the catheter insertion code, 36558, should be used for the

new catheter placement (Table 14).

Coding Tip: If the two codes are used for a catheter replacement, it is important to document the fact that the new catheter was

placed with a new venous access site and not through the old site over a guidewire.

11.5.2.3 Venous angioplasty with catheter exchange

As with placement, there are times with a tunneled catheter exchanged when significant venous stenosis

is encountered and complicates the insertion of the new catheter. In such an instance, the stenosis should

(may have to be) treated if it is deemed to be medically indicated. Since this central venous angioplasty is


38

not done via the dialysis access circuit, the code that is used should be 37248. The descriptor for this

code is – transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all

imaging and radiologic interpretation necessary to perform the angioplasty within the same vein, initial vein.

As stated, this code includes all aspects of the procedure including the radiological S&I (see Para 3.1.1.1).

As with all angioplasty procedures, the degree of stenosis present should be documented. While precise

measurements may not be possible, the comparison should be expressed in relative terms, i.e., “a

comparison of the diameter of the normal brachiocephalic vein with the area of stenosis reveals that it is less

than 50%.”

If a venous angioplasty is performed, then the use of +77001 will require a -XU modifier since this would

combine the use of a diagnostic and a therapeutic RS&I code (see page xi for details).

11.5.3 Fibrin Sheath Removal

The fibrin sheath is the most common thrombus that forms in association with the chronic dialysis catheter.

It is therefore the most common cause of catheter dysfunction. All central venous catheters likely

become encased in a layer of fibrin within a few days of insertion. This is a sleeve that eventually surrounds

the entire intra-venous portion of the catheter. The term “fibrin” sheath is a misnomer when referring to the

sheath that causes catheter dysfunction and requires treatment. Very soon afterwards its initiation as fibrin it

begins to be transformed into a sheath of connective tissue covered by endothelium. Studies have shown

that this sheath has a number of adhesions with the wall of the superior vena cava (or other vein if so

inserted). This fibro-epithelial tissue represents an intraluminal obstruction in the same manner as venous

stenosis created by neointimal hyperplasia. It should be addressed when a dialysis catheter is being

exchanged at the same site in order to avoid the risk of it interfering with the function of the newly placed

catheter. Additionally, there is concern that this process can lead to central venous stenosis which is such a

common complication of catheter use.

The code for this procedure is 36595. The descriptor for this code is – mechanical removal of pericatheter

obstructive material (e.g. fibrin sheath) from central venous device, via separate venous access. As the

descriptor indicates this code is designated as being performed from a separate site. If it is performed

from the same site, as is usual, a - 52 modifier should be attached to the code when it is submitted (see

para 1.3.2.2). The radiological S& I code that should accompany this code is 75901 (mechanical removal of

pericatheter obstructive material (e.g., fibrin sheath) from central venous device via separate venous access,

radiologic supervision and interpretation). It should be noted that it is not necessary to add a -52 modifier to

the RS&I code

Coding Tip: When a – 52 modifier is attached to a code, it is necessary to attach an explanatory statement to the submission in

addition to a copy of the operative report. It is suggested that a statement such as this be attached – “The code that most closely

describes the procedure that is being performed is 36595. However, this code specifies that the procedure be performed from a

separate site. In this instance it was performed from the same site as the procedure coded as 36581. The 52 modifier is attached

to document reduced service for fibrin sheath removal. The work being performed is 50% of that described for 36595. This coding

is in accordance with recommendations from our specialty society.”


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11.5.3.1 – Venous angioplasty performed in presence of fibrin sheath

If venous stenosis is present and treatment is deemed to be medically indicated, its treatment will also

obliterate the fibrin sheath. In this instance the later procedure, fibrin sheath removal, should not be coded.

Example 1 – The patient was referred for catheter dysfunction. Angiographic evaluation showed the presence of a fibrin sheath.

An angioplasty balloon was inserted, expanded and pulled back toward the venous entry site. A stenosis was demonstrated by

compression of the balloon. This stenosis was judged to be greater than 50% compared to the diameter of the normal vein. The

lesion was dilated. A new catheter was inserted. Radiocontrast injection showed that the fibrin sheath had been removed. The

procedure was coded as 37248.

Example 2 - The patient was referred for catheter dysfunction. Angiographic evaluation showed the presence of a fibrin sheath.

An angioplasty balloon was inserted, expanded and pulled back toward the venous entry site. No stenosis was observed. The area

was dilated. A new catheter was inserted. Radiocontrast injection showed that the fibrin sheath had been removed. The procedure

was coded as 36595-52.

11.5.4 Intraluminal Removal of Catheter Thrombus

If a thrombosed catheter is treated mechanically with an endoluminal brush or guidewire to remove a

thrombus and restore its function the use of the code 36596 is warranted. The descriptor for this code is -

mechanical removal of intraluminal (intracatheter) obstructive material from a central venous device through

device lumen. If this is done under fluoroscopic guidance, there is a supervision and interpretation code to

accompany it. This code is 75902. The descriptor for this code is - mechanical removal of intraluminal

(intracatheter) obstructive material from a central venous device through device lumen, radiologic supervision

and interpretation.

11.5.5 Intraluminal Lytic Enzyme

If a thrombosed dialysis access catheter is treated with the installation of intraluminal lytic enzyme, it

should be coded as 36593. The descriptor for this code is - declotting by thrombolytic agent of implanted

vascular access device or catheter. This is a column 2 code to 36596 (mechanical removal of intraluminal

obstructive material from central venous device through device lumen). The two codes can be used together

with a modifier on the column 2 code. A -XU modifier would be appropriate for this situation.

12. NON-TUNNELED CATHETER PROCEDURES

12.1 NON-TUNNELED CATHETER PROCEDURES

There are unique codes, separate from those that are used for tunneled catheters that are designated for

use with non-tunneled devices. It is of some importance to note that these codes are not reserved for use

with dialysis catheters. They can, in fact, be used for any type of catheter that is to be used for any purpose.

These codes are as follows:

• For non-tunneled catheter insertion, the code is 36556. The descriptor for this code is - insertion of

non-tunneled centrally inserted central venous catheter. Over 5 years of age.


40

• For non-tunneled catheter repair the code is 36575. The descriptor for this code is - repair of tunneled

or non-tunneled central venous access catheter, without subcutaneous port or pump.

• For non-tunneled catheter exchange the code is 36580. The descriptor for this code is - replacement,

complete, of a non-tunneled centrally inserted central venous catheter, without subcutaneous port or

pump through the same venous access

For non-tunneled catheter removal there is no code available. The CPT Coding Manual clearly states that

the codes for removal of tunneled catheters should not be used.

In addition to these specific codes for procedures involving non-tunneled catheters, other ancillary codes

such as those for ultrasound (+76937) and fluoroscopic guidance (+77001) as well as monitoring may be

appropriately used.

It should be remembered that if 77001 is applied in conjunction with a therapeutic RS&I code (see comments

on p. xi), it should have a -XU modifier attached.

13. SUBCUTANEOUS PORT PROCEDURES

13.1 SUBCUTANEOUS PORT PROCEDURES

There are unique codes, separate from those that are used for tunneled catheters that are designated for

use with subcutaneous ports. These are as follows:

• For the insertion of a port the code is 36561. The descriptor for this code is - insertion of tunneled

centrally inserted central venous access device, with subcutaneous port, over 5 years of age.

• For the insertion of two ports the code is 36566. The descriptor for this code is - insertion of

tunneled centrally inserted central venous access device, requiring two catheters via two separate

venous access sites, with subcutaneous port(s).

• For the replacement of a catheter associated with a port the code is 36578. The descriptor for

this code is - replacement, catheter only, of central venous access device, with subcutaneous port

or pump, through same venous access.

• For the replacement of the complete port the code is 36582. The descriptor for this code is -

replacement, complete, of a centrally inserted central venous access device, with subcutaneous port.

• For the removal of a port the code is 36590. The descriptor for this code is - removal of tunneled

central venous catheter, with subcutaneous port or pump.


41

As with non-tunneled catheters, in addition to these specific codes, other ancillary codes such as those for

ultrasound and fluoroscopic guidance during vein cannulation as well as monitoring may be appropriately

used.

14. PERITONEAL CATHETER PROCEDURES

14.1 PRIMARY CODES

There are several CPT codes that are warranted when a peritoneal catheter is inserted (Table 16).

14.1.1 Insertion of Peritoneal Dialysis Catheter, Open Surgery

The code for open or surgical insertion of the peritoneal dialysis catheter without the use of laparoscopy is

49421. The descriptor for this code is – insertion of tunneled intraperitoneal catheter for dialysis, open.

14.1.2 Insertion of Peritoneal Dialysis Catheter, Laparoscopy or Peritoneoscopy

The code for insertion of the peritoneal dialysis catheter with the use of laparoscopy or peritoneoscopy is

49324. The descriptor for this code is – laparoscopy, surgical with insertion of intraperitoneal cannula or

catheter; permanent. This code should be also used for peritoneoscopy with catheter insertion (see

Coding Tip under Para. 10.1.3 below). Injection of air into the peritoneal cavity 49400/74190 (see Para. 14.1.5

below) is bundled with this code and therefore not separately billable.

14.1.3 Insertion of Peritoneal Dialysis Catheter, Percutaneous

The code for percutaneous insertion of the peritoneal dialysis catheter performed with imaging guidance is

49418. The descriptor for this code is – Insertion of tunneled intraperitoneal catheter, complete procedure,

including imaging guidance, catheter placement, radiocontrast injection when performed, and radiological

supervision and interpretation, percutaneous. Injection of air or radiocontrast into the peritoneal cavity

49400/74190 (see Para. 14.1.5 below) is bundled with this code and therefore not separately billable. This

code may be used for any percutaneous placement technique when imaging guidance with

ultrasound and /or fluoroscopy is used. It should be noted that imaging guidance should not be interpreted

to mean a post procedure x-ray. It must be imaging guidance used during the procedure and, as with all such


42

imaging; it should be documented in both the procedure note and with a permanent image. If no imaging

guidance is used, then this code is not warranted.

Coding Tip: The key defining feature qualifying this code usage is ultrasound and/or fluoroscopy for imaging. If a peritoneoscope

is used during the procedure, it still qualifies for this code if the requisite imaging was performed. In instances in which image

documentation is required, it is recommended that the fact that an image was obtained be documented in the procedure note in

addition to inserting an image into the medical record. This will assure that if the record is reviewed at a later date the fact that an

image was obtained and saved will be documented.

14.1.4 Insertion of a Subcutaneous Extension to Remote Chest Site

The code for the insertion of a subcutaneous extension to the peritoneal dialysis catheter to extend the

catheter exit site to a remote chest site is +49435. The descriptor for this code is – insertion of subcutaneous

extension to intraperitoneal cannula or catheter with remote chest exit site.

14.1.5 Injection of Air/Radiocontrast

If air/radiocontrast is injected to obtain a peritoneogram separate from placing a peritoneal catheter, this

would warrant use of the 49400 code. The descriptor for this code is - Injection of air or contrast into peritoneal

cavity (separate procedure). Additionally, the radiological supervision and interpretation code 74190 for the

peritoneogram would also be appropriate. The descriptor for this code is - peritoneogram (e.g., after injection

of air or radiocontrast), radiological supervision and interpretation. The use of 49400/74190 codes would be

warranted only when injecting air or radiocontrast to study an existing catheter. This pair of codes is

bundled with both 43924 and 49418.

14.1.6 Ultrasound Evaluation Prior to Trocar Insertion

Some interventionalists have found that it is very beneficial to evaluate the abdomen using ultrasound prior

to insertion of the trocar in order to avoid damage to the epigastric artery and as an aid in avoiding areas of

adhesions. There is no specific code for this examination. The code 76998 is the most appropriate one to

use. The descriptor for this code is – ultrasound guidance, intraoperative. As the descriptor indicates, this

code is reserved for intraoperative use and not just for scanning the abdomen prior to prepping the

abdomen.

Coding Tip: If the abdomen is scanned after the abdomen is prepped, it should be considered intraoperative.

14.2 PERITONEAL DIALYSIS CATHETER REMOVAL

The code for removal of the peritoneal dialysis catheter is 49422. The descriptor for this code is – removal of

permanent intraperitoneal cannula or catheter.

14.2.1 Peritoneal catheter exchange

There are some instances in which a PD catheter removal is followed by the insertion of a new catheter at

the same site. This actually represents a peritoneal catheter exchange. At this time there is not a specific

code for this procedure. In this case, both a catheter removal (49422) and a catheter insertion (49418) code

should be used.


43

14.3 REPAIR OF VENTRAL HERNIA

At times when a peritoneal dialysis catheter is removed, an incisional or ventral hernia is apparent. If this is

repaired, then it is appropriate to code for the procedure. The code for repair of a ventral hernia is 49560.

The descriptor for this code is – repair initial incisional or ventral hernia; reducible. Note: although not a coding issue, there may be a privileging issue in the medical facility in which this hernia repair procedure is

being performed.

14.4 PERITONEAL DIALYSIS CATHETER REVISION

There are times when a peritoneal dialysis catheter is dysfunctional, and evaluation reveals that it can be

salvaged by repositioning. This procedure will generate several codes depending upon the specifics of what

is actually done. Unfortunately, there is no specific code for repositioning a peritoneal catheter. This

being the case, the code 49999 is warranted. The descriptor for this code is – unlisted procedure, abdomen,

peritoneum and omentum. In using this code, it is important to document and describe the details of what

was actually done. Additional codes such as the code for injection of air or contrast – 49400/74190 may

also be appropriate. If imaging is performed (peritoneogram), then the S&I code 74190 is warranted.

14.5 DELAYED CREATION OF EXIT SITE FROM EMBEDDED SUBCUTANEOUS SEGMENT

Burying the external segment of a peritoneal catheter until the site is healed and it is time to begin dialysis

has been used by some interventionalist. The code for the delayed creation of an exit site for this

embedded segment is 49436. The descriptor for this code is - delayed creation of exit site from embedded

subcutaneous segment of intraperitoneal cannula or catheter.

15. FISTULA CREATION

15.1 TYPES OF FISTULA

Fistula types can be classified into three different categories: simple direct, vein transposition and vein

translocation.

15.1.1 Simple Direct Fistula

With this type of fistula, the vein and the artery are used in their normal positions. The distal end of the vein

is freed and connected to an adjacent artery.

15.1.2 Vein Transposition Fistula

With this category of fistula, the vein is moved or transposed to a position that is better suited for the

construction of a fistula. The downstream or proximal end of the vein is left intact. The distal portion of the

vein is transposed to a position that will facilitate ease of cannulation when the fistula is used for hemodialysis.

This requires the construction of a tunnel or pocket to serve as a bed for the newly position vein.

15.1.3 Vein Translocation Fistula

With a translocation fistula, a vein is removed from one anatomical location and moved to a new one. It

involves moving the entire vein and requires the creation of both a venous and an arterial anastomosis. The


44

construction of the access is very much like the placement of a graft. The only difference is that this is the

patient’s native vein that is being used. This requires the creation of a tunnel for the vein to be positioned in

its new location.

15.2 CREATION OF FISTULA (Table 17)

15.2.1 Creation of Simple Direct Fistula

The creation of a simple direct fistula involves an incision in the skin to allow isolation of the desired artery

and vein and the creation of a single arteriovenous anastomosis. The radial-cephalic and brachial-cephalic

fistulas are examples of this type. This should be documented with the code 36821. The descriptor for this

code is – arteriovenous anastomosis, open; direct, any site (e.g., Cimino type). In doing this procedure, first

makes an incision to expose the desire artery and vein segment. Then clamps are placed on the artery

proximally and distally to allow an opening (arteriotomy) to be made. A vein is mobilized to allow the vessel

to be in the proximity of the artery. This vein is sutured to the arteriotomy opening to allow blood to flow from

the artery into the vein. This attachment may be accomplished with a side-to-side approach or with an end-

to-side approach, usually ligating and sectioning the vein distally. The operator may ligate any obvious

accessory veins to achieve optimal blood flow in the newly created fistula. In the final step, the skin is closed

in layers.

15.2.2 Creation of Vein Transposition Fistula

The three most common vein transposition fistulas are – brachial basilic, brachial-cephalic (also a simple

direct fistula, depending upon its depth) and radial-basilic. The first two of these are created in the upper arm,

the later in the forearm. A transposition fistula may be created by either of two techniques – primary

transposition or secondary transposition. In primary transposition, the vein is moved at the time the fistula is

created. Secondary transposition involves movement after the fistula has matured. Each of these two

techniques has its proponents.

15.2.2.1 Brachial-Basilic Fistula

The code for a brachial-basilic fistula creation is 36819. The descriptor for this code is – arteriovenous

anastomosis, open: by upper arm basilic vein transposition. Transposition of the basilic vein of the upper

arm involves either one long or two short incisions in the upper arm to dissect out the basilic vein. It is then

superficialized and transposed to the anterior surface of the upper arm so as to be accessible for cannulation


45

in the dialysis facility. This is done by either placing it through a subcutaneous tunnel or by creating a

subcutaneous pouch. The distal free end is anastomosed to an arterial inflow. The procedure is concluded

by closure of the skin incision.

15.2.2.2 Brachial-Cephalic Transposed Fistula

Generally, a brachial-cephalic fistula is a simple direct type of access. However, in some instances, the

cephalic vein lies too deep to be accessible for cannulation at the dialysis facility once it has been converted

into a fistula. In these instances, it can be transposed to a more superficial position to make it a usable

access. The code for a brachial-cephalic transposition fistula creation is 36818. The descriptor for this code

is - arteriovenous anastomosis, open: by upper arm cephalic vein transposition.

15.2.2.3 Forearm Vein Transposition fistula

The forearm basilic vein is not readily seen when the arm is superficially examined. For this reason, is often

spared, even in patients in whom veins have been obliterated by multiple cannulations and intravenous lines.

This vein can be utilized to create a very acceptable fistula in the forearm, but it generally needs to be

transposed to the volar surface so as to be easily accessible for cannulation once it has become mature. The

code for the creation of a forearm transposition fistula is 36820. The descriptor for this code is - arteriovenous

anastomosis, open: by forearm vein transposition. The surgery involved to transpose a forearm vein is

considerable. The entire length of the vein must be exposed in order to mobilize it. Then multiple incisions

are required to tunnel it onto the volar surface of the forearm and expose the artery for the anastomosis.

15.2.3 Creation of Vein Translocation Fistula

Although possible, vein translocation fistulas are seldom created. Other biologic and synthetic materials are

readily available that serve as well, obviating the need for this category of fistula creation in most instances.

The code for a vein translocation fistula is 36825. The descriptor for this code is – creation of arteriovenous

fistula by other than direct anastomosis (separate procedure); autogenous graft.

15.3 SECONDARY PROCEDURES

Beyond fistula creation, there are surgical needs for access maintenance. These procedures create the need

for additional codes (Table 18).

15.3.1 Revision of AVF/AVG

It is an unfortunate fact that not all fistulas that are created mature adequately for use as a dialysis access.

Additionally, there are problems that can develop over time that render a previously adequate access

unusable. Surgical revision can serve as a salvage procedure. The code for surgical revision is 36832. The

descriptor for this code is - revision, open, arteriovenous fistula; without thrombectomy, autogenous or

nonautogenous graft. This scope and details of this procedure varies. It may involve the creation of an

entirely new anastomosis or the placement of a segment of synthetic graft. It should be noted that the 36832

code also includes the completion angiogram.


46

15.3.2 Revision of AVF / AVG with Thrombectomy

Frequently the need for a surgical revision is indicated by thrombosis of the fistula. In this instance, the

process of revision is the same as above, but there is also the need to perform a thrombectomy. This makes

this overall procedure a higher order of magnitude than just a revision. The code for surgical revision with

thrombectomy is 36833. The descriptor for this code is - revision, open, arteriovenous fistula; with

thrombectomy, autogenous or nonautogenous graft.

15.3.3 Revision of AVF / AVG Involving Repair of Aneurysm

When there is a severe venous stenosis affecting a fistula, the increased pressure within the access can

produce an aneurysm, especially in areas when the wall has been weakened by multiple cannulations. In

these instances, a repair of the aneurysm is required as well as a revision to correct the basic problem. This

repair generally involves excising a portion of the vessel wall at the site of the aneurysm followed by suturing

the edges back together. The code for aneurysm repair is 36832. The 36832 code is also utilized when non-

anastomotic areas of the fistula are repaired. This includes repair of a rent or ulceration in the fistula/graft. It

should be noted that the code 36832 also includes the completion angiogram.

15.3.4 Ligation / Banding of AVF

There are instances in which there is a need to either ligate or band a fistula. In instances in which the fistula

is no longer needed, ligation can be used to eliminate it completely. In other instances, such as distal ischemia

related to the presence of a fistula, banding of the fistula may be attempted as a therapeutic maneuver.

Banding increases the resistance to blood flow in the fistula and promotes blood flow to the higher resistance

distal extremity. The code for either ligation or banding is 37607. The descriptor for this code is - ligation or

banding of angioaccess arteriovenous fistula. As is the case for all the surgical procedure (30000 series)

codes, the post procedure angiogram is bundled with the basic code.

15.3.5 Ligation of Artery of Extremity

On rare occasion, an arteriovenous fistula may develop refractory extravasation or may rupture resulting in

severe bleeding that demands definitive emergent treatment. In such an instance, it may be necessary to

ligate the feeding artery. The code for this is 37618. The descriptor for this code is – ligation, major artery

extremity.


47

15.3.6 Direct Repair of Vessel

Occasionally, a vessel is damaged and requires repair after a fistula has been created or surgically

manipulated in some manner. This may require that the vessel be repaired. In doing this, the physician makes

an incision over the site of an injured blood vessel. The vessel is dissected free of the surrounding structures.

Vessel clamps are placed. The edges of the injured vessel may be trimmed to allow repair. The vessel

defect is repaired with suture. The clamps are removed. And the skin is closed in layers. The code for this

procedure is 35206. The descriptor for this code is - repair blood vessel, direct; upper extremity.

15.3.7 Repair of Vessel with Prosthetic Graft

There are times when the repair of a vessel that has been damaged requires that a short segment of synthetic

graft be interposed in the vessel to accomplish the repair. The code for this procedure is 35266. The

descriptor for this code is – repair of blood vessel with graft other than vein; upper extremity.

15.3.8 Repair of Vessel with Vein Graft

Rather than using prosthetic material to repair an injured or diseased blood vessel a short length of vein may

be removed and used either as a patch graft to restore the correct lumen size or inserted as an interposition

graft. The code for this procedure is 35236. The descriptor for this code is - repair of blood vessel with vein

graft; upper extremity.

16. ADVERSE EVENTS

16.1 ADVERSE EVENT

There are instances in which adverse events occurred during an interventional procedure the management

of these adverse events generally involves a codable procedure. For example, if during a thrombectomy and

embolus to the distal artery occurs and embolectomy is indicated. The performance of this embolectomy

warrants a procedure code, i.e. +37186-XU.

16.2 CARDIOPULMONARY RESUSCITATION

The most serious adverse event that may encountered during an interventional procedure is a

cardiopulmonary arrest. Cardiopulmonary resuscitation is a codable event. The code for this procedure is

92950. In order to justify the use of this code actual chest compressions must have taken place. It is not

necessary for the physician to do chest compressions; it is only necessary that the physician be physically

present and supervising the procedure. The 92950 code does not include endotracheal intubation. Additional

advanced life support interventions such as drug therapy, e.g. the administration of lidocaine, atropine, etc.

may also be coded using critical care codes.

16.3 ENDOTRACHEAL INTUBATION

The code for endotracheal intubation is 31500. The descriptor for this code is - intubation, endotracheal,

emergency procedure. The use of a blind insertion airway device (BIAD) would also warrant the use of this

code.


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17. MODIFIERS

17.1 MODIFIERS

There are several modifiers that can and at times should be used in coding of the procedures performed by

interventional nephrologists (Table 19). It is important to become familiar with this and use them properly.

One should also keep in mind that when a modifier is used, the documentation must explain why the

modifier was used.

Coding Tip: In some instances, the accepted coding choice appears to vary with the local carrier. It is suggested that your choice

of modifier be based upon a discussion with your local carrier and that their definitions be used. It is important that your coding

practice be standardized and that the required documentation be provided.

17.2 FAILED PROCEDURE

What if you attempt a procedure and cannot do it? How should it be properly coded? These are important

questions. Basically, you should always code for what was actually accomplished. Beyond this, you have

three choices.

17.2.1 Code Only the Procedure Completed

One could choose to code only what was completed and omit any codes for what was attempted and not

accomplished. For example, if one started out to do an angioplasty, but could not pass a guidewire and

decided to stop after the initial angiogram, you could simply code it as a cannulation and a venogram using

the 36901 code. This would be a reasonable choice since that is all that was actually accomplished.

17.2.2 Modifier for Reduced Level of Service

The -52 modifier should be used when a service or procedure that is partially reduced or eliminated at the

physician’s discretion has occurred. This permits the reporting of reduced services without disturbing the

identification of the basic service. In some instances, another code may be available that represents the

completed portion of the intended procedure. For example, a code for a service described as complex should

not be used with a -52 modifier if a code exists for an intermediate or simple service. Only in situations in

which a separate code does not exist for the procedure as it was performed should the -52 modifier be

used. When using the -52 modifier with a surgical code which has an associated radiological S&I code, do

not attach the modifier to the radiological S&I component. Medicare does not recognize the -52 modifier

in this situation (for example 36578-52/75978). The other codes for procedures or services that were

completed should be coded normally. When billing using modifier -52, a statement explaining the reduction

of service is required. Medicare requires that you submit an operative report for a surgical procedure or

other appropriate documentation for non-surgical procedures in addition to a statement explaining how the

reduced service or procedure differs from the standard.

17.2.3 Modifier for Discontinued Procedure

One could use a different modifier to indicate that the procedure was discontinued. This modifier is -53.


49

The use of this designation indicates that the procedure was started but discontinued. It could be used as

an alternative to the -52 designation in the example quoted above.

Coding Tip: If you attempt an angioplasty, cannot complete it and choose to use either the -52 or -53 modifier, it is important that

you provide extra documentation to describe what you actually did do. This should be stated in terms of time and supplies. This

will enable the reviewer to determine a reimbursement level appropriately.

17.3 COMPLEX OR COMPLICATED PROCEDURE


50

There are times when one is required to perform substantial additional work to accomplish a procedure.

This warrants attachment of the modifier -22 to the basic code to indicate this increased level. When doing

this the reason for the additional work (i.e., increased intensity, increased time, increased technical

difficulty, or a higher than usual level of severity of the patient’s condition) must be documented. Payment

will be increased only under very unusual circumstances based upon a review of the medical record and

other documentation. Claims under this coding are priced by individual consideration. It is important to

note that submission of a claim using a code with this modifier attached does not in itself insure any additional

payment.

Coding Tip: If you choose to use the -22 modifier, it is important that you provide extra documentation in the procedure note to

describe what you did that was unusual and more than is customarily required. The reason for this requirement should also be

detailed. This will enable the reviewer to determine a reimbursement level appropriately.

17.4 SEPARATE PROFESSIONAL SERVICE

CMS designates certain radiological services (7xxxx series codes) that are eligible for separate payment of

the technical and the professional component. This is possible only if the services are performed in a facility

in which the physician does not own the equipment or employ the technical staff. These eligible services are

billed by attaching a modifier to the basic code, TC for the technical and 26 for the professional component.

If the code for the procedure is used unmodified, it indicates a complete or global service. None of the

radiological codes (7xxxx series codes) used in this manual have been designated as eligible for separate

payment under this mechanism except in the hospital setting (See discussion on page x).

17.5 MODIFIER - X{EPSU} FOR MULTIPLE DISTINCT PROCEDURES

Under certain circumstances you may need to indicate that a procedure or service was distinct or

independent from other services with which it would normally be considered as bundled. In order to do

this, one of a group of modifiers referred to as X{EPSU} modifiers (Table 20) should be used. The acronym

EPSU is derived from the first letter of the title of each of the new modifiers (XE, XP, XS, XU). It should be

noted that when one of these modifiers is used for a surgical code that is accompanied by a radiological S&I

code, the modifier is attached to both codes.

17.5.1 Modifier XE (Separate Encounter)

Modifier XE should be used to designate that the separate distinct service was performed during a separate

encounter. This would represent a repeat service performed on the same day as a previous service having

the same code. For example, if the patient had a thrombectomy performed, but rethrombosed and required

a second thrombectomy procedure later in the day. The thrombectomy code 36904 that had been used for

the first procedure should be used again with the modifier attached – 36904-XE. This would indicate that this

was a separate distinct service because it represented a separate encounter.

17.5.2 Modifier XP (Separate Practitioner)

Modifier XP should be used to designate that the separate distinct service was performed by a different

practitioner then the previous service having the same code that was provided on the same day.


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17.5.3 Modifier XS (Separate Structure)

Modifier XS should be used to designate that the separate distinct service was performed on a separate

structure.

17.5.4 Modifier XU (Separate Unusual, Nonoverlapping Service)

Modifier XU should be used to designate a separate unusual are nonoverlapping service. In other words, a

service not bundled with another service that has been coded.

Coding Tip: When using these modifiers, one should be very careful to clearly document the fact that this is a separate and distinct

procedure in addition to the medical necessity for doing the procedure.

17.6 Coding for Bilateral Surgery

The modifier -50 is a payment modifier rather than an informational one. It is attached to designated codes

to indicate that both a right and left study was performed. The use of this designation affects payment for the

procedures performed.

17.7 Subsequent Procedure Performed During Global Period

Several procedures that are performed for dialysis access have assigned global periods (Table 21). This

means that the care required during the global period following the procedure (office visits, etc) has been

included in the work and practice expense valuation of the procedure performed. This follow-up care is

therefore not separately paid. This also means that if a repeat procedure is performed during that period, it

may not be covered except in specific circumstances. There are times when a repeated or unrelated


52

procedure is done during the global period. When appropriate, there are several modifiers that can be used

to indicate the subsequent procedure is not part of the original procedure and hence a separate payment

may be available.

Those modifiers to use when a subsequent procedure is performed during the global period include

76, 77, 78 and 79. The modifier -76 is used to indicate a repeat procedure by the same physician. It should

be noted that two physicians, in the same group with the same specialty performing services on the same

day are considered as the same physician. Modifier - 77 is use to indicate a repeat procedure performed

by a different physician. These modifiers should be used when the repeat procedure is performed within

the global period but after the postoperative period – i.e. after the patient has been discharged from the

postoperative area.

The modifier - 78 is used when the patient has an unplanned return to the OR for a repeat procedure

(related to the initial procedure or complication thereof) whether by the same or a different physician.

This modifier should be used when the repeat procedure is done on the day of surgery before the patient has

been discharged from the postoperative area.

The modifier - 79 is used to indicate that the subsequent procedure was done during the postoperative period

of the first procedure but is entirely unrelated to the first procedure.

18. DOCUMENTATION 18.1 Documentation

There is an old adage – “If it’s not documented, it didn’t happen!” This should definitely be considered

true when coding procedures that were performed in the interventional lab. If you are going to code for the


53

procedure, be sure that it is documented adequately. There are several types of documentation. First, your

procedure note is very important. If something was done that justifies a code, then it should be mentioned

and/or discussed in the procedure note. This is what is reviewed for appropriateness of coding. Second,

there is radiographic documentation. This is important, it is visual and objective; anyone can see it. Thirdly,

the nurse’s note, while not a detailed record of the step-by-step aspects of the procedure, should reflect what

was actually done. Accurate coding is very important, but don’t neglect the documentation. If you need to

defend your coding later, this is the only defensive evidence that you will have.


54

Illustrative Coding Cases

Note: Only selected images are shown with each of the following illustrative cases. These images have been included to enhance understanding of the procedures that were performed. Due to space restrictions, not all images derived from the individual cases have been included. Failure to observe an image that adequately documents each procedure or a critical aspect of a procedure should not lead to the assumption that the work was not performed. Emphasis should be placed upon the narrative description of what was done and how it was coded.


55

Fistula Case 1 - Arteriovenous Fistula with Venous Stenosis in Peripheral Segment

Procedure: The patient presented with decreased access blood flow and a hyperpulsatile fistula. The access

was cannulated, and an angiogram was performed. This showed a site with severe stenosis in the basilic

vein (Figure A). This was treated with angioplasty achieving good results (Figure B). The patient was returned

to dialysis.

Discussion: This is a simple case of in angioplasty performed in the peripheral segment of the dialysis

access circuit. The code 36902 should be used. No additional codes are warranted.

Procedure Preliminary Codes Modifications Final Codes

1st cannulation --- Bundled with 36901

Angiogram of dialysis access – pre

36901 Bundled with 36902

Angioplasty Peripheral segment

36902 Primary code 36902

Angiogram of dialysis access – post

--- Bundled with 36902


56

Fistula Case 2 - Arteriovenous Fistula with Two Stenoses in Peripheral Segment

Procedure: The patient presented with decreased access blood flow and a hyperpulsatile fistula. The access

was cannulated, and an angiogram was performed. This showed 2 sites with severe stenosis, one in the

basilic vein (Figure A) and one in the axillary (Figure C). These were both treated with angioplasty achieving

good results (Figures B & D). The patient was returned to dialysis.

Discussion: In this case, there were two sites of venous stenosis; however, they were both within the

peripheral segment of the dialysis access. Therefore, only a single angioplasty can be coded. This is because

CMS has established an MUE (medical unlikely edit) of 1 for angioplasty within the peripheral segment.



Angiogram of dialysis access - pre


1st angioplasty Peripheral segment


2nd Venous angioplasty Peripheral segment

36902 Only one code allowed in peripheral segment

Angiogram of dialysis access - post



57

Fistula Case 3 - Arteriovenous Fistula with Peripheral and Central Segment Stenoses

Procedure: The patient with a radial-cephalic fistula presented with a swollen access arm and decreased

access blood flow. The fistula was cannulated and an angiogram was performed. This showed the presence

of two stenotic lesions, one in the subclavian vein (Figure A) and one in the fistula (Figure C). Both of these

were treated with angioplasty (Figures B & D) achieving good results. The patient was then discharged.

Discussion: In this case there were two sites of venous stenosis, one in the central segment and one within

the peripheral segment. Both lesions were treated successfully with angioplasty. Because one lesion is in

the peripheral segment and the other in the central segment, both can be coded. The primary code for this

case should be 36902 for the peripheral segment. The code +36907 should be used for the central segment.

This is an add-on code that must be used with a primary code which in this case should be 36902.





Angioplasty – Peripheral segment


Angioplasty – Central segment

+36907 Add-on code 36902 is primary code

+36907




58

Fistula Case 4 – Juxta-Anastomotic and Anastomotic Stenosis

Procedure: The patient presented with poor access blood flow, poor pulse augmentation and difficulty with

cannulation. The fistula was cannulated, and an angiogram was performed. This showed the presence of

juxta- anastomotic and anastomotic stenosis (Figure A). In order to treat the lesion and assess the juxta-

anastomotic portion of the feeding artery, the radial artery was selectively catheterized. Only the distal radial

artery was visualized. Two different sized angioplasty balloons were then used to treat these 2 lesions.

Treatment was successful (Figure B). The patient was then returned to dialysis.

Discussion: In this case both the anastomosis and the juxta-anastomotic fistula were involved, and both

were treated successfully; however, both sites are included in the peripheral segment of the dialysis access.

Therefore, the code 36902 covers both. The radial artery was selectively catheterized which should warrant

the code 36215; however, since this was done for angioplasty balloon positioning, using the code is not

appropriate. The arteriogram code 75710 is also not appropriate because only a small portion of the inflow

arteries was examined. This procedure is bundled in the primary code, 36902.





1st order selected catheterization, arterial

36215 Disqualified because performed for angioplasty

balloon positioning

Arteriogram --- Not done for diagnostic purposes

1st angioplasty of peripheral segment


2nd angioplasty of peripheral segment

36902 Only one angioplasty allowed in peripheral

segment




59

Fistula Case 5 – Juxta-Anastomotic and Anastomotic Stenosis with Venous Stenosis in Access

Procedure: The fistula was cannulated retrograde approximately 10 cm above the anastomosis and an

angiogram was performed. This showed the presence of juxta- anastomotic stenosis which also involved the

anastomosis (Figure A). In addition, a venous lesion was seen proximal in the cannulation zone (Figure C).

Because of the concern that flow was inadequate, the radial artery was selectively catheterized, and an

arteriogram was done to examine the entire length of the brachial artery down to the anastomosis. No

problems were detected. Two angioplasty balloons were then used to treat the anastomosis and adjacent

fistula lesion as in Case 5. Treatment was successful (Figure B). Because the proximal lesion could not be

accessed from the first cannulation site, a second cannulation was performed, and the proximal lesion was

treated successfully using an 8 X 4 balloon (Figure D). The patient was returned to dialysis.

Discussion: In this case, three stenotic lesions are present - the anastomosis, the juxta- anastomotic fistula and the body of the fistula. Since all three of these are within the peripheral segment of the dialysis access, only one code, 36902 is warranted. Even though a second cannulation was required to treat the more proximal lesion, this is also bundled in the 36902 code. The selective catheterization code 36215 is warranted because it was done in order to facilitate diagnostic imaging of the brachial artery. The arteriogram code is also warranted since there was a medical indication and the entire brachial artery was examined. The code for this procedure, 75710, should have an XU modifier attached because of concurrent use of diagnostic and therapeutic RS&I. The therapeutic RS&I was bundled within the 36902 code.


60





2nd cannulation --- Bundled with 36902


36215 Warranted since done for diagnostic purposes

36215

Arteriogram 75710 Meets definition, XU modifier required because of

concurrent use of diagnostic and therapeutic RS&I

75710-XU

1st Angioplasty of peripheral segment


2nd Angioplasty of peripheral segment

36902 Only one angioplasty allowed in peripheral

segment




61

Fistula Case 6 – Anastomotic Stenosis with Venous Stenosis in Central Vein


cannulation. By physical examination, an inflow problem was diagnosed. The fistula was cannulated

retrograde, approximately 10 cm above the anastomosis and an angiogram was performed. This showed the

presence an anastomosis stenosis (Figure A). In addition, a venous stenosis lesion was seen in the

subclavian vein associated with multiple large collaterals (Figure C). In order to treat the lesion and assess,

the juxta- anastomotic portion of the radial artery was selectively catheterized. An angioplasty was then

performed to treat the anastomosis. Treatment was successful (Figure B). Because the subclavian lesion

could not be accessed from the first cannulation site, a second cannulation was performed, and the proximal

lesion was treated successfully using a 12 X 4 balloon (Figure D). The patient was returned to dialysis.

Discussion: In this case, both the peripheral segment and the central segment of the dialysis access were treated with angioplasty. Both of these can be coded. The code for the central lesion is an add-on code, +36907. Even though a second cannulation was required for the central lesion, it is bundled within the code for the angioplasty. The selective catheterization that was performed should not be coded since it was performed for angioplasty balloon positioning and not for diagnostic imaging.


62





2nd cannulation --- Bundled with +36907


36215 Disqualified because performed for angioplasty

balloon positioning

Arteriogram 75710 Not done for diagnostic purposes



Angioplasty Central segment


+36907

Angiogram of access - post



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Fistula Case 7 – Juxta-Anastomotic and Anastomotic Stenosis with Feeding Artery Stenosis


cannulation. The fistula was cannulated, and an angiogram was performed in a retrograde direction. This

showed the presence of juxta- anastomotic stenosis which also involved the anastomosis (Figure A). In order

to treat the lesion and assess the juxta- anastomotic portion of the feeding artery, the brachial artery was

selectively catheterized. An angioplasty balloon was then used to treat both the anastomosis and adjacent

fistula lesion. Treatment was successful (Figure B). However, access blood flow was not felt to be optimal

and pulse augmentation was less than optimal. The vascular catheter was advanced up to the level of the

subclavian artery and an arteriogram of the feeding artery was performed. This showed a stenotic lesion in

the upper brachial artery (Figure C). This lesion was successfully treated with angioplasty (Figure D) and the

patient was returned to dialysis.

Discussion: In this case, there is a lesion present within the feeding artery. Since this lesion is more than 2 cm from the anastomosis, it warrants a separate code - the code for an arterial angioplasty, 37246. The code for the dialysis access lesion is 36902. The arteriogram can be coded with 75710 since it was done for a valid medical indication and the entire brachial artery was examined. The 75710 code requires a XU modifier because of concurrent use of diagnostic and therapeutic RS&I. The therapeutic RS&I is bundled within the angioplasty code. The fact that the selective catheterization was performed in order to achieve a diagnostic study qualifies it for coding.


64






36215 Qualified procedure 36215

Arteriogram 75710 Medically indicated, XU modifier required because of concurrent use of diagnostic

and therapeutic RS&I

75710-XU



Arterial angioplasty 37246 Qualifies since more than 2 cm from anastomosis

37246


--- Bundled with angioplasty codes


65

Fistula Case 8 - Juxta- Anastomotic Stenosis Approached from Radial Artery

Procedure: The patient presented with poor access blood flow and poor pulse augmentation. Physical

examination and ultrasound evaluation indicated the presence of juxta- anastomotic stenosis. It was decided

to approach the lesion via a retrograde radial artery cannulation. The site used was more than 2 cm from the

anastomosis. After a sheath was inserted, an arteriogram was performed to visualize only the anastomosis,

juxta- anastomotic fistula, and adjacent fistula. This showed only stenosis of the anastomosis and juxta-

anastomotic fistula (Figure A). A guidewire was utilized to manipulate a vascular catheter across the

anastomosis and into the fistula. An angiogram was performed to visualize the fistula and its venous outflow

up through the superior vena cava. No other lesions were detected. The stenotic lesion in the juxta-

anastomotic portion of the fistula was treated with angioplasty. This was successful (Figure B) and a follow-

up angiogram showed good blood flow in the fistula.

Discussion: To treat this case, the radial artery was cannulated directly, and the fistula was selectively catheterized. Since the purpose of this procedure was to gain entry into the dialysis access, neither the nonselective code for cannulation nor the selective code can be used. Both are bundled with the 36901-6 code group. Since the arteriogram was not performed for diagnostic purposes, the arteriogram code 36140 is not warranted.


Radial artery cannulation

36140 Bundled with 36901-2



1st order selected catheterization, venous

Bundled with 36902

Arteriogram 75710 Nor done for diagnostic purposes



Angiogram analysis access - post



66

Fistula Case 9 - Arteriovenous Fistula Thrombosis

Procedure: The patient presented with a thrombosed brachial- basilic fistula. The fistula was cannulated in

an antegrade direction and radiocontrast was injected which showed marked stenosis of the access with

scattered thrombi of various size (Figure 8). A 9 Fr aspiration catheter was inserted, and thrombus was

aspirated. Because residual thrombus was present, 2 mg of tPA was administered. After waiting five minutes

for the tPA to act, the stenotic lesions were treated with angioplasty (Figure B). The fistula was cannulated a

second time in a retrograde direction and additional stenotic lesions were treated with angioplasty (Figure

C). The brachial artery was selectively catheterized, and an arteriogram was performed to visualize the

brachial artery and its drainage to look for pathology and rule out the possibility of emboli. This was negative.

Following this, an angiogram was performed which showed that blood flow in the fistula was good. The patient

returned to dialysis.

Discussion: In this case, the thrombectomy procedure itself would warrant the code 36904. Although two modalities were used to perform the thrombectomy, they are both covered under the same code. However, the tPA can be billed using the appropriate J code. Since an angioplasty was also performed, the higher level thrombectomy code 36905 should be applied. This bundles both thrombectomy and angioplasty in the peripheral segment. Although two lesions were present and were treated from separate access sites, they were all within the peripheral segment of the dialysis access. Therefore, only a single code is warranted. Selective catheterization of the brachial artery was necessary. This warrants a selective code. An arteriogram was performed. The medical indication for this study was a thrombosed fistula and the need to rule out embolization, therefore a 75710 code for this procedure is warranted. However, in this instance it should have a -XU modifier attached because this code is a diagnostic RS&I code which is used in association with a therapeutic RS&I code - bundled with 36902.


67







36215 Performed for diagnostic purposes

36215

Arteriogram 75710 XU modifier required because of concurrent use of

diagnostic and therapeutic RS&I

75710-XU

1st Angioplasty Peripheral segment


2nd Angioplasty Peripheral segment

--- Only one permitted in peripheral segment

Thrombectomy - mechanical

36904 Primary code With addition of PTA

becomes 36905

36905

Thrombectomy - tPA 36870 Only one code allowed

Charge for medication - tPA

J2997 2 X for 2 mg J2997 X 2




68

Fistula Case 10 – Arteriovenous Fistula with Accessory Vein Treated with a Coil

Procedure: The patient presented with failure to mature. Physical examination revealed the presence of an

accessory vein. The fistula was cannulated in a retrograde direction and an angiogram was performed. This

revealed a large accessory vein (Figure A). The accessory vein was selectively catheterized with a vascular

catheter (Figure B). An endovascular coil was placed in the vein (Figure C). A follow-up angiogram performed

through the catheter showed no flow beyond the coil (Figure D).

Discussion: The first procedure performed in this case was an angiogram of the dialysis access which

should be coded with 36901. This is the primary code for the procedure. Manipulation with a vascular catheter

was required to selectively catheterize the vessel for coil placement; however, this part of the procedure is

bundled with 36901. Placement of the venous coil warrants the code +36909. This is an add-on code which

requires a primary code. In this case the primary code is 36901. The code + 36909 is a bundled code and

includes all parts of the procedure.


Cannulation --- Bundled with 36901

Angiogram of dialysis access




Venous coil + 36909 Add-on code 36901 is primary code

+36909


--- Bundled with +36909


69

Fistula Case 11 – Arteriovenous Fistula with Accessory Field of Veins Treated with a Coil

Procedure: The patient presented with a newly created fistula with difficult cannulation of the upper portion

of the fistula. Physical examination revealed the presence of an accessory vein. The fistula was cannulated

in a retrograde direction and an angiogram was performed. The main accessory vein (arrow in each image)

was very short and branched early (Figure A). Each of the two major branches was selectively catheterized

with a vascular catheter and a selective angiogram of each was performed (Figures B and C). A coil was

placed in each of the vein branches. A follow-up angiogram performed through the catheter shows no flow

beyond the coils (Figure D).

Discussion: The first step this procedure was the performance of an angiogram should be coded with 36901.

This is the primary code for the procedure. The main trunk of the accessory vein appeared to be too short to

safely place a coil, so each major branch was coiled. This basically represents a field of veins. The accessory

veins were selectively catheterized: however, this part of the procedure is bundled with 36901.Even though

two veins were coiled, only a single code can ever be coded with the venous coil code.


70







2nd order selected catheterization, venous


2nd order selected catheterization, venous



+ 36909


--- Bundled with + 36909


71

Fistula Case 12 – Arteriovenous Fistula with Two Accessory Veins Treated with Coils

Procedure: The patient presented with a newly created fistula with difficulty cannulating the upper portion of

the fistula. Physical examination revealed the presence of 2 accessory veins. The fistula was cannulated in

a antegrade direction and an angiogram was performed. This revealed the presence of two accessory veins,

one coming off either side of the fistula (Figure A). Each of the two veins was selectively catheterized with a

vascular catheter and both were coiled (Figures B & C). A follow-up angiogram performed through the

catheter shows no flow beyond the coils in either vessel (Figure D).

Discussion: This case began with the performance of an angiogram which should be coded with 36901. This is the primary code for the entire procedure. In this case, both accessory veins were selectively catheterized: however, all selected catheterization required for the procedure is bundled with 36901. Even though two veins were coiled, only a single venous coil code can ever be coded. The appropriate code for this is +36909.


72









Venous coil +36909 Add-on code 36901 is primary code

+ 36909




73

Fistula Case 13 - Arteriovenous Fistula with Accessory Vein and Misplaced Coil

Procedure: The patient presented with failure of a newly placed fistula to mature. Physical examination

revealed the presence of an accessory vein. The fistula was cannulated in a retrograde direction and an

angiogram was performed. This revealed a large accessory vein (Figure A). The accessory vein was

selectively catheterized with a vascular catheter and 2 coils were placed at the origin of the vein from the

fistula. Placement on the first coil was good; however, there was not room enough for the second coil and it

extended out into the fistula itself (Figure B). An Amplatz snare was placed in the vein and used to capture

the misplaced coil (Figure C) which was then successfully extracted (Figure D). The final angiogram looked

good. The patient was returned to dialysis.

Discussion: This procedure began with an angiogram of the dialysis access. This should be coded with

36901 and is the primary code for the procedure. The accessory veins were selectively catheterized:

however, all selective catheterization required for the procedure is bundled with 36901.Placement of the

venous coil warrants the code + 36909. Even though two coils were placed, the code can only be used once.

One of the coils that was placed had to be retrieved because of malplacement. This complication, managed

by the use of a snare, warrants a code. The code for this procedure is 37197 which also bundles the

radiological S&I, and imaging guidance for the procedure.


74








+ 36909

Use of snare 37197 Separate procedure 37197




75

Fistula Case 14 – Arteriovenous Fistula with Accessory Vein Treated by Ligation

Procedure: The patient presented with a newly created fistula with difficulty cannulating the upper portion of

the fistula. Physical examination revealed the presence of an accessory vein which was large and visible.

The fistula was cannulated in a retrograde direction and an angiogram was performed which demonstrated

the presence of the accessory vein (Figure 8). After local anesthesia with lidocaine, an incision was made

over the accessory vein and it was ligated. A postprocedure angiogram showed a good result (Figure B). The

surgical site was sutured, and the patient was discharged to dialysis.

Discussion: The first step in this procedure was the performance of an angiogram of the dialysis access.

This should be coded with 36901. An accessory vein was identified and was treated by surgical ligation. The

recommended code for this procedure is 37607. In this instance, the postprocedure angiogram is bundled

with the surgical procedure and therefore does not warrant a separate code.


Cannulation --- Bundled with 36901 -



Ligation of vein 37607 Separate procedure 37607




76

Fistula Case 15 – Brachial-Cephalic Fistula with Dialysis Access Steal Syndrome

Procedure: The patient presented with stage IV dialysis access steal syndrome. Ultrasound evaluation

revealed a blood flow greater than 3 L/min in the patients brachial-cephalic fistula. The fistula was cannulated

in a retrograde direction and an angiogram was performed (Figure C). A guidewire was inserted, and a

selective catheterization of the brachial artery was performed. A vascular catheter was used to perform an

angiogram of the brachial artery down to the level of the anastomosis (Figure A). A second angiogram was

performed to evaluate the arterial blood flow down to the level of hand (Figure B). Both of these were normal.

A 4-mm angioplasty balloon was then passed over the guidewire and positioned at the anastomosis of the

fistula. An incision was made over the distal fistula and a band was placed just proximal to the anastomosis

with the angioplasty balloon inflated. The balloon was then deflated and removed reducing the inflow to a 4-

mm orifice (Figure D) and the postprocedure blood flow was 1200 mL/ min.

Discussion: This case began with a duplex ultrasound procedure to evaluate the access and measure

access blood flow. Since a second imaging modality was done, this ultrasound code was dropped. The

access was cannulated, and an angiogram of the dialysis access was performed. This should be coded with

36901. This was followed by a selective catheterization of a first order artery which warrants the code 36215.

An arteriogram of the extremity was performed which is coded as 75710. In this instance it should have a -

XU modifier attached because this code is a diagnostic RS&I code which is used in association with a

therapeutic RS&I code – bundled within 37607.The banding procedure should be coded with 37607. This

also includes the post-banding angiogram. The follow-up ultrasound study does not warrant a code since

only one imaging modality can be coded.


77


Access ultrasound - pre 93990 Cannot code for two imaging modalities



36901 Highest level code for imaging modality

36901


36215 Meets requirement for medical indication

36215



75710-XU

Banding of access 37607 37607

Angio of access - post --- Bundled with 37607

Access ultrasound - post

93990 Cannot code for two imaging modalities


78

Fistula Case 16 - Fistula Case with Hand Ischemia Due to Arterial Lesions

Procedure: The patient with a brachial-basilic fistula presented with symptoms suggesting stage III dialysis

access steal syndrome. Ultrasound evaluation of the fistula revealed a blood flow all 800 mL/min. The fistula

was cannulated in a retrograde direction and an angiogram was performed. A guidewire was then inserted,

and the brachial artery was selectively catheterized. A vascular catheter was passed over the guidewire and

advanced up the brachial artery to the level of the subclavian artery. An arteriogram was performed to

visualize the entire length of the brachial artery. Two arterial stenotic lesions were noted. One lesion was in

the axillary artery (Figure A), the other was in the brachial artery (Figure B). No other abnormalities were

noted. Both lesions were treated successfully with angioplasty. A postprocedure angiogram showed no

evidence of complications. A postprocedure ultrasound evaluation revealed a blood flow of 1600 mL/min. the


Discussion: The first procedure performed in this case was an ultrasound evaluation. The code for this is 93990; however, since a second imaging modality was done which is represented by a higher-level code, the ultrasound code was dropped. The access was cannulated, and an angiogram was performed. This should be coded with 36901. This was followed by a selective catheterization of a first order artery which warrants the code 36215. Although the vascular catheter was advanced up to the level of the subclavian artery, a second order selected catheterization is not warranted since this simply represents a continuation of the brachial artery and required no work to accomplish. An arteriogram of the extremity was performed which should be coded as 75710. However, in this instance it should have a -XU modifier attached because this code is a diagnostic RS&I code which is used in association with a therapeutic RS&I code - bundled with 37246. Two separate arterial lesions were seen each one of which was in a separate named artery. Therefore, both can be coded. The first of these should be coded with 37246. The second should be coded with 37247. Both codes are all inclusive. A follow-up duplex ultrasound study was performed to assess the blood flow; however, this does not warrant a code since only one imaging modality can be coded. In this case, the 36901 represents a higher-level code and should be used.


79






36901



36215



75710-XU

1st Angioplasty arterial

37246 37246

2nd Angioplasty arterial

37247 Both arterial angioplasty can be coded

37247

Postprocedure arteriogram

75710 Bundled with 37246 and 37247

Access ultrasound - post

93990 Cannot code for two imaging modalities


80

Fistula Case 17 – Radial-Cephalic Fistula with Dialysis Access Steal Syndrome

Procedure: The patient with a radial-cephalic fistula presented with stage III dialysis access steal syndrome.

Ultrasound evaluation revealed a blood flow greater than 1.2 L/min. The fistula was cannulated in a retrograde

direction and an angiogram was performed. A guidewire was inserted and a selective catheterization of the

radial artery. The catheter was then advanced into the brachial and up to the subclavian artery. The vascular

catheter was used to perform an angiogram of the arterial system all the way down to the palmar arch (Figures

A & B). This revealed no significant problems. The distal radial artery selectively catheterized and a vascular

catheter was positioned just distal to the anastomosis (Figure C). An endovascular coil was then inserted into

the distal radial artery (Figure D). A postprocedure ultrasound evaluation was performed which revealed a

blood flow of 800 mL/min.

Discussion: This case began with a duplex ultrasound procedure to evaluate the access and measure

access blood flow. The code for this is 93990; however, since a second imaging modality was performed

which represents a higher-level code, this ultrasound code was dropped. The access was cannulated, and

an angiogram of the dialysis access was performed. This should be coded as 36901 This was followed by a

selective catheterization of a first order artery (the radial artery) this should be coded with 36215. A second

order selected catheterization of the artery (the brachial artery) is not warranted since this is contiguous with

the radial artery. An arteriogram of the extremity was performed which is coded as 75710 because it meets

the qualifications for medical indication. However, in this instance it should have a -XU modifier attached

because this code is a diagnostic RS&I code which is used in association with a therapeutic RS&I code -

bundled with 37242. The distal radial artery was then selectively catheterized, and an arterial coil was placed


81

which has its own unique code, 37247. This code is all inclusive. A follow-up duplex ultrasound study was

performed to assess the blood flow; however, this should not be coded since only one imaging modality can

be coded and 75791 represents a higher-level code.






36901

First 1st order selected catheterization, arterial


36215

Second 1st order selected

catheterization, arterial


Requires an XS modifier to indicate a separate

procedure

36215-XS



75710-XU

Arterial coil 37242 37242

Angiogram of access dialysis - post




82

Graft Case 1: Lower Extremity Graft with Stenosis at Both the Venous and Arterial Anastomoses

Procedure: The patient with a right thigh, loop graft was referred to the access center because of low blood

flow on dialysis. After the graft was cannulated, an angiogram was performed which showed an area of 80%

stenosis at the venous anastomosis (Figure A). This was treated with angioplasty obtaining a good result

(Figure B). A retrograde radiocontrast injection showed a 90% stenosis at the arterial anastomosis (Figure

C). The graft was cannulated a second time to address this lesion. After a guidewire was placed across the

arterial anastomosis, the lesion was dilated with good result (Figure D). A final angiogram showed good flow

and good results from the angioplasties. The patient was discharged to dialysis.

Discussion: Even though this graft is in the lower extremity, both the arterial and venous anastomosis these

are counted as part of the dialysis vascular access. This case was initiated by cannulation of the graft followed

by an angiogram. This portion of the procedure would warrant the code 36901. However, since an angioplasty

was performed, the code should be changed to 36902 which would bundle all aspects of procedure. Even

though the graft was cannulated twice, and two angioplasties were performed, the entire procedure would be

included in the 36902 bundle.


83





1st angioplasty – Peripheral segment


2nd cannulation --- Bundled with 36902,

2nd angioplasty – Peripheral segment

36902 Only one angioplasty code can be used within the

peripheral segment




84

Graft Case 2 – Arteriovenous Graft with Thrombosis and Both Arterial and Venous Stenosis

Discussion: The patient with a thrombosed forearm loop graft was referred to the access center. To perform

the thrombectomy procedure using thromboaspiration, it was necessary to cannulate the graft 2 times. In

addition to the thrombectomy procedure, stenotic lesions were noted at both the venous and the arterial

anastomoses (Figure A). A third stenotic lesion was noted in the subclavian vein (Figure B). All 3 of these

stenotic lesions were treated with angioplasty. The brachial artery was selectively catheterized, and an

arteriogram was performed in which the entire arterial drainage down to the level of the hand was examined

to rule out the possibility of an arterial embolus. This study was negative. Following these procedures, a

postprocedure angiogram was performed which showed good resolution of the stenoses and good blood

flow. The patient was referred back to the dialysis center.

Discussion: As is typical for a case of this sort, the first step was cannulation of the graft and performance

of an angiogram of the central vessels. This is bundled within the code 36901. Although the graft was

cannulated two times, both are bundled within the primary code. The performance of the thrombectomy

warrants the code 36904; however, since this was combined with an angioplasty the bundled code 36905

which includes both thrombectomy and angioplasty would be indicated. The two stenotic lesions within the

peripheral segment of the dialysis access (at the venous anastomosis and at the arterial anastomosis) only

warrant a single code which is bundled within the 36905 thrombectomy code. The subclavian lesion warrants

a separate code since it was within the central vein area. The appropriate code for this procedure should be

+36907 which is an add-on code used with the primary code 36905. Since an arteriogram was performed for

a valid medical indication, it can be coded with 75710. However, in this instance it should have a -XU modifier

attached because this code is a diagnostic RS&I code which is used in association with a therapeutic RS&I

code - bundled with 36905. The post procedure angiogram is also bundled with 36905.


85






Thrombectomy - thromboaspiration


becomes 36905

36905



2nd Angioplasty of peripheral segment

36902 Bundled with 36905 Only 1 code allowed in

peripheral segment

Venous angioplasty - central

+36907 Add-on code 36 5 is primary code

+36907



1st order selective catheterization - artery


36215

Arteriogram of extremity 75710 Requires an XU modifier because of simultaneous

use of diagnostic and therapeutic R S&I codes

75710-XU

Angio of access - post --- Bundled with 36905


86

Graft Case 3 - Arteriovenous Graft with Thrombosis Treated Leaving Residual Clots

Procedure: The patient with a forearm loop graft was referred to the access center for thrombosis. The graft

had several pseudoaneurysms associated with it. To perform the thrombectomy, the graft was cannulated

two times. The basic thrombectomy procedure was performed using thromboaspiration in which a sheath

was inserted and then a Fogarty catheter (Figure A) was used to remove thrombus which was aspirated from

the side arm of the sheath. A lesion at the venous anastomosis was dilated with angioplasty. Following this,

an angiogram through a vascular catheter was performed to visualize the entire graft. This showed the

presence of multiple areas of residual thrombus (Figure B). To better access this area, the graft was

cannulated a third time and a Trerotola thrombectomy device (Figure C) was used to remove these thrombi.

Following this, another angiogram was performed to visualize the entire course of the graft. The graft

appeared clean (Figure D) and blood flow was good. The brachial artery was selectively catheterized, and

an arteriogram was performed to visualize the brachial artery from its origin at the subclavian artery to rule

out any inflow problems or distal emboli. This appeared normal. The patient was returned to dialysis.

Discussion: The first step in this procedure was to cannulate the graft and perform an angiogram of the

central vessels. These steps would be covered with the code 36901. A second cannulation was performed

to complete the thrombectomy. This cannulation would also be covered by 36901. The thrombectomy

warrants the code 36904. This was followed by an angioplasty in the peripheral segment which would warrant

a 36902. However, in this case, both procedures would be bundled in the code 36905 which would cover

everything that was done up until this point. To complete the procedure and remove all residual clots, the

graft was cannulated a third time. These would also be bundled with 36905. The thrombectomy was


87

performed using two different techniques. However, a thrombectomy performed by any technique or by

multiple techniques, still warrants only a single code. The brachial artery was selectively catheterized to

perform the arteriogram. This warrants the code 36215. An arteriogram was performed and should be coded

with 75710 because it meets the qualifications for medical indication. However, in this instance it should have

a -XU modifier attached because this code is a diagnostic RS&I code which is used in association with a

therapeutic RS&I code - bundled with 36905. The post procedure angiogram is also bundled with 36905.







36904 Primary code Includes all methods With addition of PTA

becomes 36905

36905

Angioplasty Peripheral segment -

pre


3rd cannulation --- Bundled with 36905

Thrombectomy – Trerotola thrombectomy

device

36905 Cannot code for second thrombectomy,

thrombectomy performed by any procedure included in

primary code



36215



75710-XU




88

Graft Case 4 – Arteriovenous Graft with Thrombosis and Peripheral Artery Embolus

Procedure: The patient with upper arm straight graft was referred to the access center with thrombosis. To

perform the thrombectomy procedure using the thromboaspiration, it was necessary to cannulate the graft 2

times. In addition to the thrombectomy procedure, a stenotic lesion was noted at the venous anastomosis.

This lesion was treated with angioplasty. During the procedure the patient began to complain of severe pain

in the ipsilateral hand. The brachial artery was selectively catheterized, and an arteriogram was performed

in which the entire arterial drainage down to the level of the hand was examined. An embolus was observed

in the brachial artery just before the bifurcation. An embolectomy was performed using a balloon catheter.

Afterwards, a postprocedure angiogram was performed which showed good resolution of the stenosis,

removal of the embolus and good access blood flow. The patient was referred back to the dialysis center.

Discussion: This procedure was initiated by a cannulation followed by an angiogram of the central vessels.

This procedure warrants the code 36901 which is a bundled code including all of this procedure. The second

cannulation of the graft it is also bundled with this code. The thrombectomy then was performed which

warrants the code 36904; however, since this was combined with an angioplasty of the peripheral segment,

the bundled code 36905 which includes both thrombectomy and angioplasty should be warranted. An arterial

embolus occurred as a complication. This required an arteriogram for confirmation. This warrants the code

75710 because it meets the qualifications for medical indication. However, in this instance it should have a -

XU modifier attached because this code is a diagnostic RS&I code which is used in association with a

therapeutic RS&I code - bundled with 36905. The management of this complication warrants a code. The

first step in this procedure was a 1st order arterial selective catheterization of the brachial artery which would

warrant the code 36215. The code for an embolectomy is + 37186. This is an add-on code must be used in

conjunction with another basic code, in this case the code for thrombectomy 36905. Although it is a column

2 code to 36905 and is mutually exclusive, it can be use with the modifier -XU (+37186-XU). The post

procedure angiogram is also bundled with 36905 and +367186-XU.


89


1st cannulation --- 36901

Angiogram of dialysis access -pre





becomes 36905

36905





36215

Arteriogram of extremity - pre

75710 Requires an XU modifier because of simultaneous


75710-XU

Embolectomy +37186 All-inclusive add-on code cannot stand alone must be

used with another code It should be used with an -

XU modifier

+37186-XU

Arteriogram of extremity - post

75710 Bundled with +37186




90

Graft Case 5 – Arteriovenous Graft with Thrombosis and Delayed Peripheral Artery Embolus

Procedure: The patient presented at dialysis with moderately severe pain in the ipsilateral hand the day

following a thrombectomy procedure. The patient had an upper arm straight arteriovenous graft with several

pseudoaneurysms. At the access center, the graft was cannulated in a retrograde direction and the brachial

artery was selectively catheterized. An arteriogram was performed which showed the presence of a filling

defect in the brachial artery just proximal to the bifurcation (Figure A). Using a balloon catheter, an embolus

was removed from the site. Following this procedure, a repeat arteriogram showed good flow in the brachial

artery and its tributaries (Figure B). The patient’s hand pain resolved.

Discussion: The embolectomy code, + 37186, should be used here. It is an add-on code and cannot be

used without the use of a primary code. In this case the basic angiogram code, 36901, would apply. The

artery was selectively catheterized which warrants the code 36215. The arteriogram was warranted because

of the need to evaluate the brachial artery for an embolus. The code for this procedure requires a XU modifier,

75710-XU, because of the simultaneous use of diagnostic and therapeutic RS&I procedures (the therapeutic

RS&I is bundled with +37186).







36215

Arteriogram of extremity - pre

75710 Requires an XU modifier because of simultaneous


75710-XU

Embolectomy +37186 Add-on code 36901 is primary

+37186

Arteriogram of extremity- post



91

Graft Case 6 – Arteriovenous Graft with Thrombosis, Separate Remote Thrombus

Procedure: The patient with a forearm loop graft was referred to the access center because of thrombosis of their graft. The graft was cannulated, and an angiogram of the venous outflow was performed. A large thrombus was in present in the axillary vein (Figure A), a greater than 50% stenosis at the venous anastomosis and a greater than 50% stenosis of the brachiocephalic (Figure B). Using and aspiration catheter, the axillary thrombus was removed. The thrombectomy procedure on the graft was accomplished using thromboaspiration which required a second cannulation. The stenotic lesions at the venous anastomosis and in the brachiocephalic (Figures B & C) were then treated with angioplasty. The brachial artery was selectively catheterized to perform an arteriogram of the extremity to rule out inflow problems and check for arterial emboli. A postprocedure angiogram showed good access blood flow, the axillary thrombus was completely resolved, and the stenotic lesions were completely dilated. The patient was referred back to dialysis.

Discussion: In this case with a thrombosed forearm graft and central vein stenosis, a separate remote

thrombus was present in the axillary vein which required removal. This thrombus was completely separated

from the thrombus within graft and did not represent an embolus. All the codes used for a routine dialysis

access thrombectomy with angioplasty should be used for this case. Since the dialysis access is defined as

extending from the arterial anastomosis (including 2 cm of adjacent artery) through the central venous system

including the superior vena caval, removal of the separate thrombus within the axillary vein is included in the

basic thrombectomy code.


92










2nd Angioplasty of central segment

36902 +36907 +36907



36215



75710-XU


75971 Bundled with angioplasty code


93

Graft Case 7 – Thrombosed HeRO Device

Procedure: A patient with a HeRO device in the right upper extremity presented to the access facility with

thrombosis of the device. After the upper arm was prepped and draped, a site approximately 4 cm above the

arterial anastomosis was cannulated in an antegrade direction. A guidewire was inserted followed by the

placement of a sheath. The catheter portion of the device was opened using a 4 Fr angioplasty balloon

catheter (Figure A). Thrombus was aspirated from the side-arm of the sheath during this procedure. The

device was then cannulated approximate 4 cm below the junction between the graft material and the catheter

in a retrograde direction. A second sheath was inserted. Using the 4 Fr Fogarty catheter, the arterial

anastomosis and graft were cleared of thrombus (Figure B) which was aspirated from the side arm of the

sheath. A stenosis greater than 50% was present at the arterial anastomosis. This was treated with

angioplasty (Figure C). Following this procedure, the brachial artery was selectively catheterized, and an

arteriogram was performed to visualize the distal brachial artery and its drainage down to level the wrist to

rule out the possibility of arterial emboli. This is normal and a a final angiogram revealed that blood flow in

the device was optimal (Figure D). The patient was referred back to dialysis.

Discussion: The HeRO device is classified as a dialysis graft. The coding for the thrombectomy procedure

performed on this device is basically the same as that for coding a thrombectomy procedure on a graft. This

procedure began with cannulation an angiogram which we coded as 36901. This was then changed to 36904

by the thrombectomy procedure and subsequently to 36905 because in angioplasty was done in addition to

the thrombectomy. The device was cannulated twice, both of which are bundled with the 36905 code. The


94

artery was selectively catheterized for diagnostic purposes which would warrant a first order artery selective

catheterization code 36215. An arteriogram was performed which was medically indicated and warrants the

code 75710. However, in this instance it should have a -XU modifier attached because this code is a

diagnostic RS&I code which is used in association with a therapeutic RS&I code - bundled with 36905. The

post procedure angiogram is also bundled with 36905.



Angiogram of access - pre





becomes 36905

36905





36215



75710-XU


75971 Bundled with angioplasty code


95

Stent Case 1 – Grade 3 Venous Rupture with Angioplasty Requiring Stent

Procedure: A patient with a radial-cephalic fistula presented with poor access blood flow and a hyper-

pulsatile fistula. The fistula was cannulated in an antegrade direction and an angiogram was performed. What

appeared to be complete obstruction of the basilic vein was observed; however, it was possible to advance

the guidewire beyond this point. The stenosis was treated with angioplasty (Figure A) which resulted in a

rupture of the vein (Figure B). Conservative measures were unsuccessful; the hematoma was progressive

and pulsatile. The lesion was stented (Figure C) which restored blood flow to the basilic vein (Figure D).

Discussion: In this case in which an angioplasty within the peripheral segment (36902) was performed. This

should be coded as a straight forward angioplasty within the peripheral segment. However, there was a

complication - rupture of the vein. This required the placement of a stent. Although this a complication of the

procedure, coding is warranted. The venous stent code – 36903 is the appropriate code to use. This is a

bundled code which includes all components of the procedure.







Stent placement Peripheral segment





96

Stent Case 2 - Long Elastic Lesion Requiring 2 Stents

Procedure: A patient with a forearm graft presented with poor access blood flow and a hyper-pulsatile fistula.

The fistula was cannulated in an antegrade direction and an angiogram was performed. A long stenotic lesion

was observed in the cephalic vein (Figure A). Multiple dilatations with an angioplasty balloon were performed;

however, the lesion was elastic, and the results were poor (Figure B). The lesion was stented, but required

2 stents for complete coverage of the lesion (Figure C & D).

Discussion: The coding for this case would begin as for a routine angioplasty, 36901 superseded by 36902.

It would change to 36903 with the placement of the stent. The stent code can be used only once even though

two stents were placed because only a single vessel, the dialysis access, was stented. The stent code 36903

is a bundled code which includes all components of the procedure including the angioplasty.







1st Stent placement Peripheral segment


2nd Stent placement Peripheral segment

36903 Only 1 stent in peripheral segment can be coded




97

Stent Case 3: Central Venous Stenosis Requiring a Stent

Procedure: A patient with a brachial- cephalic fistula was referred because of poor blood flow and edema of

the ipsilateral arm. An angiogram was performed which showed a 90% stenosis of the brachiocephalic vein

(Figure A). This lesion was treated with a 12X4 angioplasty balloon. Full effacement of the balloon was

achieved (Figure B); however, there was marked recoil of the lesion with a 70% residual (Figure C). The

lesion was stented successfully (Figure D). Follow-up angiogram showed good result with good blood flow.

Discussion: The coding for this case should begin as for a routine angioplasty, 36901 for the cannulation

and angiogram. This is the primary code for the case. The add-on code +36907 should be added for the

central vein angioplasty. It would be superseded by +36908 with the placement of the stent. The stent code

+36908 is a bundled code which includes all components of the procedure including the angioplasty.






+ 36907 Bundled with + 36908

Stent placement Central segment


+36908




98

Stent Case 4: Peripheral and Central Venous Stenosis Both Requiring a Stent

Procedure: A patient with a brachial- basilic fistula was referred to the access center because of poor access

blood flow, a hyperpulsatile fistula and mild edema of the access arm. After the fistula was cannulated an

angiogram was performed which showed a 75% stenosis in the basilic vein (Figure A) and a 60% lesion in

the mid-left brachiocephalic vein (Figure C). Both lesions were treated with angioplasty which required a

10X4 angioplasty balloon for the peripheral lesion and a 14X4 for the central lesion. Both lesions were elastic

and were both treated by the placement of an endovascular stent (Figures B & D). The follow-up angiogram

showed good result and good blood flow.

Discussion: In this case both a peripheral and a central venous stenosis were treated with angioplasty. This

permits the coding 2 venous angioplasty procedures because the lesions are in different segments of the

dialysis access 36902 and + 36907. Since both were followed by stent placement, the angioplasty code would

be superseded by the bundled code which includes angioplasty and stent placement, 36903 and +36908,

respectively. The code for the peripheral segment procedure is the primary code for the central segment

procedure which is an add-on code. These codes are totally inclusive of the entire procedure.


99








+36907 Bundled with +36908

Stent placement Peripheral segment


Stent placement central segment

+ 36908 Add-on code 36903 is primary code

+ 36908




100

Stent Case 5: Arterial Anastomosis and Peripheral Artery Stenosis Both Requiring a Stent

Procedure: A patient with the brachial-cephalic fistula was referred to the access center for low blood flow

and poor pulse augmentation. After the fistula was cannulated an angiogram was performed in a retrograde

direction. This showed the presence of a 90% juxta- anastomotic and anastomotic stenosis (Figure A). This

lesion was treated with angioplasty which resulted in extravasation. To control this complication, a stent was

required at that location (Figure B). Blood flow in the access was still felt to be less than optimal. A selective

catheterization of the brachial artery was performed and an arteriogram of the entire artery from the

subclavian artery downward was obtained. This showed a 60% stenosis within the axillary artery (Figure C).

This lesion was also treated with angioplasty. The result obtained in the axillary artery was felt to be less than

optimum so a stent was placed there also (Figure D). A follow-up angiogram showed a good result and good

blood flow. The patient was returned to the dialysis facility.

Discussion: In this case, the stent placed at the arterial anastomosis should be considered IIb within the

peripheral segment of the dialysis access. The stent placed within the axillary artery should be considered

independent of the access since it is more than 2 cm removed from the anastomosis. For this reason, both

stents can be coded. The codes for initial cannulation and diagnostic angiography should be coded as 36901.

This would be superseded by 36902 when the angioplasty is performed and by 36903 with the placement of

the stent in addition to the angioplasty. Selective catheterization of a first order artery was performed which

should be coded as 36215. The arteriogram warrants the code 75710 because it meets the qualifications for


101

medical indication. However, in this instance it should have a -XU modifier attached because this code is a

diagnostic RS&I code which is used in association with a therapeutic RS&I code - bundled with 36903 and

+36908. The arterial angioplasty performed in the axillary artery would warrant the code 37246 which is a

bundled code including all aspects of that procedure.


1st cannulation ---- Bundled in 36901


36901 Bundled in 36902 because of concurrent use of




Stent placement peripheral segment




36215



75710-XU

Arterial angioplasty – non-access


Arterial stent - non-access





102

Stent Case 6 - Stent Placed from Site Other Than Dialysis Access Circuit

Procedure: A patient with a brachial-cephalic fistula in the left upper arm and a tunneled dialysis catheter in

the right internal jugular was referred to the access center with marked swelling of the ipsilateral arm. The

access was cannulated in an antegrade direction and an angiogram was performed. This showed total

occlusion of the left brachiocephalic vein. Multiple attempts were made to pass a guidewire and across the

lesion but were unsuccessful. A guidewire was inserted through the tunneled catheter in the right internal

jugular vein and the tunneled catheter was removed. A vascular catheter was introduced, and an angiogram

was performed in order to identify the junction between the left brachiocephalic vein and the superior vena

cava. The vascular catheter and guidewire were advanced up to the level of the superior vena cava and the

left brachiocephalic vein was selectively catheterized (Figure A). Using the catheter and guidewire together,

the lesion in the left brachiocephalic vein was crossed. An attempt was made to snare the distal end of the

guidewire from the dialysis access cannulation site, but was unsuccessful. The lesion in the brachiocephalic

vein was dilated using a 12 X 4 angioplasty balloon via the right internal jugular site. Even though there was

complete balloon effacement, the lesion had elastic recoil leaving a residual > 50 %. An endovascular stent

was placed (Figure B). The final result of the stent was good, and blood flow through the fistula was good.

The patient was discharged to the dialysis facility.

Discussion: In this case the dialysis access was cannulated, and an angiogram was performed this would

warrant the code 36901. It was not possible to pass the guidewire through that site, so the right internal

jugular site was used. This involved removal of the tunneled dialysis catheter which would warrant the code

36589. An angiogram was performed from the left internal jugular which creates the possibility of a code for

this procedure; however, it is bundled with the final procedure performed. The left brachiocephalic vein was

selectively catheterized; however, this was done in order to gain entry into the dialysis access circuit.

Therefore, this selective catheterization code is bundled in the code for the procedure that follows. An

angioplasty was performed in the central segment which would create the possibility for the use of the add-


103

on code +36907. Since the stent which was placed was placed using the right internal jugular site rather than

the dialysis access, it should be coded as 37238.This code bundles the accompanying angioplasty which

would eliminate +36907.


1st cannulation ---- Bundled in 36901



Tunneled catheter removal

36589 Separate procedure

36589

Selective catheterization of 1st

order vein



+36907 Bundled with 37238

Stent placement in central segment

not from dialysis access

37238 Separate procedure

37238




104

Catheter Case 1 –Tunneled Dialysis Catheter Insertion

Procedure: The right internal jugular vein was cannulated using ultrasound and fluoroscopic guidance

(Figure A). Difficulty was encountered in passing the guidewire, so an angiogram was performed (Figure B).

No abnormality was seen. The guidewire was passed with further manipulation and positioned in the inferior

vena cava (Figure C). A 28-cm dialysis catheter was then placed without difficulty (Figure D). The catheter

tip was positioned in the right atrium.

Discussion: This was a straight forward placement of a right internal jugular tunneled dialysis catheter.

Difficulty was encountered in passing the guidewire resulting in the performance of an angiogram. This does

not warrant a code because all angiographic studies are bundled with the basic fluoroscopic code.


Cannulation & contrast injection

36005 Bundled with 36558 & +77001

Ultrasound guidance +76937 Image record required +76937

Fluoroscopic guidance +77001 +77001

Catheter insertion 36558 36558


105

Catheter Case 2 – Tunneled Dialysis Catheter Insertion with Stenosis of Right IJ

Procedure: The right internal jugular vein was visualized with US and looked good. However, after it was

cannulated, the guidewire would not pass. An angiogram was done which showed a severe stenosis of the

right internal jugular vein (Figure A). With multiple attempts, the guidewire was eventually passed down to

the atrium. An angioplasty was performed with an 8 X 4 balloon (Figure B). After the angioplasty, the superior

vena cava was visualized and looked good (Figure C). The catheter was then inserted (Figure D) without

further difficulty.

Discussion: Since this angioplasty is not performed in the dialysis access circuit, it should be coded as

37248. The code +77001 needs a XU modifier since there a therapeutic code it is also being used. The

therapeutic RS&I code is bundled with 37248. Catheter insertion should be coded with 36558 as usual.

Procedure Preliminary Codes

Modifications Final Codes

Cannulation & contrast injection 36005 Bundled with 36558 & +77001

Ultrasound guidance +76937 XU modifier required because of concurrent use of diagnostic and

therapeutic RS&I, Image record required

+76937-XU

Fluoroscopic guidance + 77001 XU modifier required because of concurrent use of diagnostic and

therapeutic RS&I

+ 77001-XU

Venous angioplasty 37248 Dialysis access circuit not used

37248



106

Catheter Case 3 – Tunneled Dialysis Catheter Insertion with Obstructed Right IJ

Procedure: The patient had a large right internal jugular vein on ultrasound. It was cannulated, but the

guidewire would not pass. After several failed attempts, an angiogram was performed which showed that the

right internal jugular vein was totally obstructed (Figure A). The left internal jugular vein was then cannulated

and a tunneled catheter was placed without further difficulty (Figure B).

Discussion: In this case, an attempt was made to place a catheter in the right internal jugular vein. The

guidewire could not be passed so radiocontrast was injected for diagnostic evaluation. The vein was found

to be occluded. Normally. the cannulation of the vein for the placement of a catheter is bundled with the basic

catheter placement code; however, the cannulation on the right side was not associated with a catheter

placement. Therefore, it warrants a separate code. The code 36005 is recommended for this situation.

Additionally, the angiogram would warrant a code. Not being associated with the catheter insertion, it would

be coded according to the specific vein involved. In this case, it should be 75860 which would need an XU

modifier to indicate that it was a separate procedure done under unusual circumstances. The catheter

placement on the left side should be coded in the regular manner.


Cannulation & contrast injection

36005 Not at site of new catheter placement

36005

Angiogram of right internal jugular vein

75860 Requires a XU modifier to indicate separate procedure

75860-XU


Fluoroscopic guidance + 77001 + 77001



107

Catheter Case 4 – Tunneled Dialysis Catheter Insertion with Obstructed Right IJ Using Target for Cannulation Procedure: The right internal jugular vein was not apparent by ultrasound at the site normally used for catheter insertion. However, examination higher up revealed a patent vein. This was cannulated and radiocontrast was injected. This showed that the lower portion of the internal jugular vein was extremely stenotic (Figure A), but radiocontrast did pass into the superior vena cava. An angioplasty balloon was inserted at that site and passed down to the location of the stenosis in the supraclavicular area (Figure B) and angioplasty was performed. The Inflated balloon was then used as a target for cannulation which was performed using a micro puncture needle (Figure C). The microguidewire was inserted into the balloon and carried downward (Figure D). The deflated angioplasty balloon was then removed, and catheter insertion progressed from the lower site without difficulty.

Discussion: In this case, the ultrasound guided cannulation of the first venous site not used for catheter insertion. Therefore, this should be coded as +76937. The vein cannulation with contrast injection at a site not used for catheter insertion would warrant the code 36005; however, this would be bundled with the venous angioplasty which was performed. The venous angioplasty was medically indicated because of the presence of the stenotic lesion. Since the angioplasty was not performed via the dialysis access circuit, the code 37248 should be used. Since this was done from a site different from that used for the catheter placement, it does not represent a decreased level of service and therefore does not require a 52 modifier (see case below where 52 modifier is required). The angioplasty balloon was used as a target for cannulation. The code normally used for this procedure is 77002; however, this code is a column 2 code to the column one code +77001 which is mutually exclusive. Therefore, 7702 cannot be applied. The remainder of the coding for this catheter insertion would follow the normal coding procedure for catheter placement. The code +76937 is


108

used 2 times because two separate independent sites were cannulated. However, only one would require a XU modifier, the one that was performed for catheter placement (the second one). The other (the first one) usage of + 76937 would not require the modifier since it is being used for cannulation other than catheter placement (see discussion on page xi).


Ultrasound guided cannulation

+76937

XU modifier not required because used for

cannulation of other than catheter placement

Image record required, Clear documentation

necessary to indicate that this is a separate procedure

+ 76937-XU

Cannulation and contrast injection

36005 Bundled with basic procedure code


37248

Target used for cannulation

77002 Column 2 code with +77001, mutually exclusive

Ultrasound guidance +76937 XU modifier required because of concurrent use of

diagnostic and therapeutic RS&I,

Image record required

+76937

Fluoroscopic guidance + 77001 XU modifier required because of concurrent use of


+ 77001-XU



109

Catheter Case 5 – Tunneled Dialysis Catheter Exchange at Same Site

Procedure: A dysfunctional catheter presented needing to be exchanged. After the subcutaneous cuff was

dissected free, it was pulled back so that the tip was just below the clavicle and an angiogram was performed

to determine if a fibrin sheath was present (Figure A). No sheath was noted. A guidewire was inserted into

the inferior vena cava. The old catheter was removed over the guidewire. After the guidewire was cleansed,

the new catheter was inserted over the guidewire which was then removed (Figure B). The catheter was

tested with a 10-mL syringe and found to be functioning well. It was sutured in place and the patient returned

to dialysis.

Discussion: This is a straightforward catheter exchange with the new catheter being placed at the same

location as the one being removed. The code for catheter exchange in this situation is 36581. It was done

under fluoroscopic guidance and should be coded with + 77001. Radiocontrast was injected to evaluate for

fibrin sheath. This is not coded, however, since it is bundled with the + 77001 code.


Fluoroscopic guidance + 77001 + 77001

SVC angiogram 75827 Bundled with +77001

Catheter exchange 36581 36581


110

Catheter Case 6 – Tunneled Dialysis Catheter Exchange with Change of Site

Procedure: A dysfunctional catheter (Figure A) presented needing to be exchanged due to the presence of

catheter -related bloodstream infection. After the subcutaneous cuff was dissected free, the tunnel was found

to be infected. The catheter was removed, and the original site was abandoned. A new site was selected on

the opposite side and the new catheter was inserted without difficulty (Figure B). The catheter functioned

well, and the patient was returned to dialysis.

Discussion: This is case of catheter exchange, but one in which the new catheter was placed at a different

site. This basically represents 2 completely separate procedures. First, a catheter removal was performed

which warrants the code 36589. Second, a catheter insertion was performed which warrants the code 36558.

Both of these were done with ultrasound guidance.


Catheter removal 36589 36589


Fluoroscopic guidance +77001 +77001



111

Catheter Case 7 – Tunneled Dialysis Catheter Exchange with Fibrin Sheath

Procedure: After the cuff of the right internal jugular catheter was freed using blunt dissection, the catheter

was pulled back so that the tip was just below the clavicle and radiocontrast was injected. A fibrin sheath was

seen (Figure A). This was disrupted using an 8 X 4 angioplasty balloon (Figures B and C). No venous

stenosis was observed. The new catheter was inserted over the guidewire (Figure D).

Discussion: The performance of an angiogram does not warrant a code because all angiographic studies

are bundled with the basic fluoroscopic code. The codes 354763/75978 are not indicated. Although an

angioplasty balloon was utilized to disrupt the sheath, no stenosis was present. A -52 modifier should be

applied to the code for fibrin sheath disruption because it was not done from a separate site and therefore

represents a decreased level of service. The code +77001 requires a XU modifier since there is also a

therapeutic 70000 series code being used.


Fluoroscopic guidance +77001 XU modifier required because of concurrent use of

diagnostic and therapeutic RS&I, Image record required

+ 77001-XU



Venous angioplasty 37248 Not warranted – no stenosis

Fibrin sheath disruption 36595/75901 52 modifier – decreased level of service, the basic

code specifies that the procedure be done from a

separate site

36595-52/75901


112

Catheter Case 8 – Tunneled Dialysis Catheter Exchange with Fibrin Sheath and Venous Stenosis

Procedure: After the cuff of the right IJ catheter was freed using blunt dissection, the catheter was pulled

back so that the tip was just below the level of the clavicle and radiocontrast was injected. A fibrin sheath

was seen (Figure A). An 8 X 4 angioplasty balloon was inserted. With inflation of the balloon, a greater than

50% stenosis was observed in the entry vein (Figure B). This was dilated with full effacement of the balloon.

A follow-up angiogram done at the time of catheter insertion revealed that the fibrin sheath was no longer

present. Incidental to the angioplasty, the fibrin sheath was also disrupted (Figure C). The new catheter was

inserted without difficulty (Figure D).

Discussion: This was an exchange of a right internal jugular tunneled dialysis catheter complicated by both

a venous stenosis and a fibrin sheath. The performance of an angiogram does not warrant a code because

all angiographic studies are bundled with the basic fluoroscopic code. The basic procedure performed in this

case is related to the venous stenosis which was treated with angioplasty and should be coded as such.

Since angioplasty was not performed via the dialysis access circuit it should be coded as 37248. This code

also includes the radiological supervision and interpretation. Who Because it represents a decreased level

of service a -52 modifier should be attached. The fibrin sheath disruption was incidental to the basic

procedure and was not coded. The code, +77001, needs a XU modifier since it is being used concurrently

with the therapeutic 75978 code.


113


Fluoroscopic guidance +77001 XU modifier required because of concurrent use of

diagnostic and therapeutic RS&I, Image record required

+ 77001-XU




Decreased level of service requires -52 modifier

37248-52

Fibrin sheath disruption 36595/75901 Not done Disruption was incidental


114

Catheter Case 9 – Tunneled Dialysis Catheter Exchange with Complicated Central Vein Stenosis

Procedure: The patient was referred for catheter dysfunction. The catheter that was in place was viewed

under fluoroscopy. The course of the dysfunctional catheter (diagonal) suggested that it was in the azygous

vein (Figure A). A lateral view confirmed that this was the case (Figure B). It was not clear as to whether the

SVC was patent or not. Using a Kumpe vascular catheter the guidewire was manipulated into the superior

vena cava and an angiogram was performed that showed that it was patent (Figure C). The new catheter

was then passed over the guidewire into the SVC (Figure D).

Discussion: This was a case that was complicated by stenosis of the central veins causing dilatation of the

azygous vein and partial obstruction of the entry into the superior vena cava. Catheterization was necessary

in order to gain access to the superior vena cava. This warrants the appropriate code for that procedure,

36010. The angiogram of the SVC is bundled in the fluoroscopy code. Documentation on this case should

clearly describe the indication for performing the superior vena caval catheterization.


Fluoroscopic guidance +77001 + 77001

Catheterization of SVC 36010 36010



115

Catheter Case 10 - Tunneled Dialysis Catheter Exchanged for Acute Catheter

Procedure: A patient with an acute catheter in the right internal jugular vein was referred for a tunneled

dialysis catheter. The acute catheter entry site was in a position optimal for a tunneled catheter and appeared

clean (Figure A & B). A guidewire was inserted through the acute catheter and passed down into the inferior

vena cava. The acute catheter was removed over the guidewire and replaced with a 14 Fr dilator (Figure C)

The tunneled catheter was tunneled up from the anterior chest and inserted into the same site (Figure D).

The catheter was tested and sutured. With good blood flow, the patient was referred back to dialysis.

Discussion: In this case, an old acute dialysis catheter was exchanged for a new tunneled dialysis catheter.

Since there is no code for the removal of an acute dialysis catheter, it is recommended that this procedure

be coded as a catheter placement rather than a catheter exchange. This would involve the use of the

fluoroscopy guidance code as well as a catheter placement code. Since ultrasound guidance was not used,

that code does not come into play in this case.





116

Catheter Case 11 – Tunneled Dialysis Catheter Inserted by Wiring the Tunnel

Procedure: A patient presented having their catheter come out inadvertently during the night. Examination

of the exit site revealed that it was clean with no evidence of inflammation or infection. A 5 Fr dilator was

inserted into the old catheter exit site and a guidewire was passed through the dilator up the old tunnel (Figure

A). Under fluoroscopy, the guidewire was observed to turn downward at the internal jugular vein site (Figure

B). It was advanced further down into the inferior vena cava (Figure C). A new catheter was then inserted

over the guidewire and advanced to an optimal position without difficulty. The catheter functioned well. The


Discussion: In this case, a new catheter was inserted using the old catheter exit site and tunnel. It is

recommended that this procedure be coded as a catheter exchange even though a catheter was not

removed. Except for that, the procedure that was performed is basically the same as a catheter exchange.





117

Peritoneal Dialysis Catheter Case 1 – PD Catheter Insertion Using Percutaneous Technique

Procedure: The patient was referred to the access center for the placement of a peritoneal dialysis catheter. Ultrasound was utilized to determine the thickness of the panniculus, the absence of underlying bowel and the position of the inferior epigastric artery. After incising and dissecting down to the level of the peritoneum, the abdomen was entered with a micropuncture needle and a 5 Fr catheter (micro-dilator) was threaded over the micro-guidewire into the peritoneal cavity. Radiocontrast was injected to confirm the position of the catheter (Figure A). A stiff guidewire was then inserted. Using this guidewire, dilators, and tunneling tools a peritoneal dialysis catheter was inserted. Its position was confirmed with a radiocontrast injection (Figures B & C). This also confirmed the absence of kinks in the catheter tunnel (Figure D).

Discussion: This case represented a straight forward uncomplicated example of a percutaneous peritoneal dialysis catheter inserted into the abdomen using the Seldinger technique with fluoroscopic guidance. The code for percutaneous insertion of the peritoneal dialysis catheter performed with imaging guidance is 49418. This is a bundled code which includes the image guidance as well as a catheter placement. This code is appropriate to use whether imaging is done by fluoroscopy or ultrasound. As with all imaging procedures, image documentation is required. Radiocontrast was injected into the peritoneal cavity as part of this procedure. The code for this is 49400 and its accompanying radiological S & I code is 74190; however, these are bundled with the catheter insertion code 49418.


Image guidance - intraoperative

76998 Bundled with 49418, may be either ultrasound or fluoroscopy, image

documentation is required

PD catheter insertion -percutaneous

49418 49418

Radiocontrast injection into peritoneum

49400/74190 Bundled with 49418


118

Peritoneal Dialysis Catheter Case 2 – PD Catheter Insertion Using Peritoneoscope

Procedure: The patient was referred to the access center for the placement of a peritoneal dialysis catheter. Under local anesthesia the abdomen was insufflated with air. A peritoneoscope was introduced and an exploration of the abdomen was performed. This detected no abnormalities. The insertion tract was then dilated and a swan neck peritoneal dialysis catheter was placed without difficulty. Discussion: This was an uncomplicated peritoneal dialysis catheter placement using peritoneoscopy. The code for this procedure is 49324 (the same code be used for laparoscopic placement). Because no imaging was performed, there is no code for imaging. Air was injected into the peritoneal cavity as part of this procedure. The code for this is 49400 and its accompanying radiological S & I code is 74190; however, these are also bundled with the peritoneal dialysis catheter insertion code 49324.


Air injection in the peritoneal cavity

49400/74190 Bundled with 49324

PD catheter insertion -peritoneoscopy

49324 49324


119

Peritoneal Dialysis Catheter Case 3 - PD Catheter Insertion by Peritoneoscopy with Imaging

Procedure: The patient was referred to the access center for the placement of a peritoneal dialysis catheter. After the patient was prepped draped, the abdomen was examined using ultrasound because of the history of abdominal surgery and the presence of an abdominal midline scar. Free movement of the viscera was observed in the region that was planned for the catheter insertion. The abdomen was insufflated with CO2 and a peritoneoscope was inserted. Peritoneoscopic examination of the abdomen revealed the presence of adhesions in the right lower quadrant. The peritoneal catheter was placed in the left side of the pelvis using a guidewire and fluoroscopic guidance. The catheter functioned well. Discussion: This was an uncomplicated peritoneal dialysis catheter placement using imaging along with peritoneoscopy. Because of the imaging which was performed, this procedure warrants the code for percutaneous PD catheter placement. The code for this procedure is 49418. As with any type of imaging, a permanent image record should be entered into the record. CO2 was injected into the peritoneal cavity. The injection of air or radiocontrast into the peritoneal cavity 49400/74190; however, this is bundled with 49418 and therefore not separately billable.



49418 49418

CO2 injection into peritoneum

49400/74190 Bundled with 49418


120

Peritoneal Dialysis Catheter Case 4 - Radiocontrast Injection and Manipulation of PD Catheter Procedure: The patient was referred to the access center with a dysfunctional peritoneal dialysis catheter. After the patient was prepped and draped, radiocontrast was injected into the peritoneal cavity through the catheter with direct fluoroscopic observation. Radiocontrast was observed to exit the catheter only through the proximal side hole. A hydrophilic guidewire was inserted through the catheter to clear any intraluminal obstruction. The guidewire was advanced and manipulated to disrupt pericatheter adhesions. A follow-up radiocontrast injection through the catheter revealed that it was functioning normally with radiocontrast flowing into the peritoneal cavity. Discussion: This procedure consisted of two parts: the injection of radiocontrast to diagnose the problem and catheter manipulation in order to resolve the problem. Radiocontrast injection into the peritoneal cavity is coded as 49400. The accompanying radiological S & I code is 74190. Both of these would be warranted in this case. There is no code available for the catheter manipulation portion of this procedure. If radiocontrast is not injected and only the catheter manipulation is described is performed, the code 76000 can be used. This is the code for fluoroscopy up to one-hour physician time as a separate procedure. This code should not be used in this case because the fluoroscopic component is included in the radiological S&I code 74190.



49400/74190 49400/74190

Catheter manipulation 49999 Unlisted code Detailed documentation is

important for reimbursement

49999


121

Peritoneal Dialysis Catheter Case 5 - PD Catheter Removal with Repair of Ventral Hernia Procedure: The patient is scheduled to begin hemodialysis with a peripheral arteriovenous access. He was referred to the access center for removal of the peritoneal dialysis catheter that has been in place for the past three years. The areas around the external and internal cuffs were anesthetized with lidocaine. A small incision was made over the internal cuff. The catheter peripheral to this cuff was clamped and cut. The internal cuff was freed with blunt dissection and that portion of the catheter was extracted. The external cuff was then freed, and the peripheral segment of the catheter was removed. At the time of catheter removal, the presence of a ventral hernia was recognized. This was repaired. The incision was closed. The patient was discharged and given an appointment to return for suture removal. Discussion: This procedure consisted of two parts: the removal of the peritoneal dialysis catheter and repair of a ventral hernia. Both components warrant a code. The code for peritoneal catheter removal is 49422. The repair of the ventral hernia should be coded as 49560.


PD catheter removal 49422 49422

Repair of ventral hernia 49560 49560


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Peritoneal Dialysis Catheter Case 6 - PD Catheter Exchange

Procedure: The patient was referred to the access center with a dysfunctional catheter. Attempts were made to manipulate the catheter and restore function. This involved the injection of radiocontrast into the peritoneum. These attempts were unsuccessful. A decision was made to exchange the catheter. After anesthetizing the site of the internal cuff, a small incision was made over the cuff and the catheter was clamped peripherally. The catheter was transected peripheral to the clamp. The internal cuff was freed and after a guidewire had been inserted, it was extracted from the peritoneum. The guidewire was then maneuvered to an optimal position using fluoroscopic guidance and a new catheter was inserted at the same site. After the internal cuff had been positioned, the new catheter was tunneled to a new exit site. Attention was then turned to the retained external segment of the old catheter. The area around the external cuff was infiltrated with lidocaine and it was freed. The catheter segment was then removed and discarded. The new catheter flushed easily. The patient was discharged. Discussion: This procedure was composed of two parts: a catheter removal and a catheter insertion. Since

the new catheter was placed using the same entry site as the old catheter, this actually represents a

peritoneal dialysis catheter exchange. At this time, there is not a specific code for this procedure. In this case

as described, it is recommended that both a catheter removal (49422) and a percutaneous catheter insertion

(49418) code should be used. This is recommended in this case based upon the fact that this catheter

insertion was done percutaneously. If another technique is used, then this code should be changed. Catheter

manipulation was also performed; however, there is no specific code for this. The code for radiocontrast

injection (49400/74190) would be appropriate; however, it is bundled with 49418 as it is the fluoroscopic

guidance for the entire procedure.


Catheter manipulation No available code

Image guidance - intraoperative

76998 Bundled with 49418, may be either ultrasound or fluoroscopy, image

documentation is required

PD catheter removal 49422 49422


49418 49418


49400/74190 Bundled with 49418

Documents

Coding of Procedures in Interventional Nephrology 2018