# Billable fistulagram?



## suela923@aol.com (Oct 28, 2014)

I am being told to bill for the fistulogram with a 52 modifier.  I am not so sure I agree as the doctor states this was intervention only.  Any advice?  Thanks,
Sue 

Procedure: Left arm fistulogram. Balloon angioplasty of stenotic segment.

 Indication: High venous pressures.

 Results: Patient was identified and brought to the vascular unit. The left arm was prepped and draped in the usual sterile fashion. 2% lidocaine was used to infiltrate the skin over the left arm fistula. A micropuncture catheter was placed without difficulty. Fistulography showed severe stenoses in 2 areas in the midportion of the AV fistula.

 Note that prior fistulogram was performed. This was an intent to treat procedure. Using a 0.018 guidewire I was able to traverse the stenotic segments were somewhat tortuous. Balloon angioplasty was then performed of the stenotic segments in the midportion of the fistula. Balloon angioplasty was performed to 6 mm, then 8 mm. Completion fistulogram showed significant improvement in the stenotic segments without recoil or residual stenoses. The central veins reviewed as patent without stenoses on a prior study therefore these were not evaluated on this exam.
  Result Impression  
 Severe stenoses in 2 areas of the midportion of the AV fistula. Both successfully treated with balloon angioplasty with good result.


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## Amy Pritchett (Oct 28, 2014)

In this case, the correct CPT code to bill for the procedure is 35476. I did see that this was an AV fistula, correct? Also, here is a Tip:
When a venous AV fistula or graft angioplasty was performed, the procedure is reported using the following codes:
35476 (Transluminal balloon angioplasty, percutaneous; venous) for the procedure. 75978, [Transluminal balloon angioplasty, venous (e.g., subclavian stenosis), radiological supervision and interpretation.] for the imaging.
Remember to report only one intervention per segment. According to CPT? guidelines, that means reporting 35476 and 75978 only once per segment, even if the physician uses multiple balloon catheters to open multiple lesions or inflates a balloon multiple times.
The fistulogram is bundled into the procedure as the balloon angioplasty is the hierarchy of the procedures performed. Now, if you work for an ASC or Outpatient Hospital, you would code the fistulogram in the ICD-9-PX codes for facility reimbursement. 
Also, if the physician performed more than one puncture of the artery, make sure to code the 36012 (selective catheter placement, venous system, second order, or more selective branch).
Hope this helps!!


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## suela923@aol.com (Oct 28, 2014)

Oh I am sorry, I wasn't clear...I did bill for the angioplasty I was just not agreeing with billing for the fistulgram itself since the doctor stated intervention only.  Would you bill 36147-52 as well as 35476, 75978?  Thanks!


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## Amy Pritchett (Oct 28, 2014)

No. Since the fistulogram is included in the hierarchy of the coding for the balloon angioplasty, it would not be coded with a -52 modifier. The physician is correct. You would not code the fistulogram due to it being more "interventional" and included in the CPT code hierarchy for the balloon. 
Does this help?


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## suela923@aol.com (Oct 28, 2014)

Yes, thank you.


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## Amy Pritchett (Oct 28, 2014)

You can always message me or, you can email me at vpofaapc@gmail.com for any IR questions you have. Glad this helped. Have a great day


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## suela923@aol.com (Oct 28, 2014)

I will!  Thanks so much!


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## zoting.arvind@gmail.com (Oct 30, 2014)

hi Amy,
but 36147 code has no CCI conflict with 35476 neither the code 35476 has no description of including 36147 in coding guideline and do we have to code 35476 only when there is venous angioplasty is done on fistula leaving the access of fistulogram cpt codes like 36147 and 36148. please clarify


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## ASH527 (Oct 31, 2014)

Hi Amy,

I also thought that in the case of dialysis access you can bill the fistulogram and the angioplasty as these rules differ somewhat from other vascular procedures.


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