Cardiology Coding Alert

Following old rules could cost you $550 per procedure.

This has been a year of changes for coding angioplasty of arteriovenous dialysis grafts. The latest Correct Coding Initiative (CCI) version, effective Oct. 1, 2010, adds to the list with a column swap that could be good news for your practice.

Start With the 35475, 35476 Edit Facts

The two codes involved in the edit are the following:

• 35475 -- Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel
• 35476 -- ... venous.

Old way: Until Oct. 1, 2010, CCI's edit for 35475 and 35476 looked like this:

35476              35475

As a result, 35475 (arterial) was bundled into 35476 (venous).

New way: Effective Oct. 1, 2010, CCI swaps the edit pair for physician edits, so that 35476 (venous) is bundled into 35475 (arterial):

35475              35476

Grasp How Column Change Affects Fee

According to CCI rules, if you report both codes in a column 1/column 2 edit pair to Medicare (or another payer who adopts CCI edits), the payer will reimburse you for the code in the column 1 position only (unless circumstances support overriding the edit with a modifier, in which case you will receive reimbursement for both). Medicare's national rate for 35475 is higher than for 35476, so the column swap places the higher valued code in the column 1 position:

Recall 2010 Deletion of G0392, G0393

This new CCI edit column swap comes on the heels of other significant 2010 changes for coding percutaneous transluminal angioplasty (PTA) of arteriovenous (AV) grafts and fistulas.

Change 1: HCPCS 2010 deleted the codes you previously used for the service when reporting to Medicare. Those codes were G0392 (Transluminal balloon angioplasty, percutaneous; for maintenance of hemodialysis access, arteriovenous fistula or  graft; arterial) and G0393 (... venous), says Michele Midkiff, CPC-I, PCS, RCC, executive director of Coding Affiliates Inc., an interventional coding service in Mountain View, Calif.

The deletion of those codes meant that coders returned to using 35475 and 35476 for AV fistula or graft PTA, Midkiff notes. You should use 35475 when the physician performs angioplasty of the AV fistula arterial anastomosis, and use 35476 for venoplasty of the venous anastomosis. (Remember, anastomosis is the interconnection of the artery and vein.)

Compare CCI Edit to Coding Recommendations

But the code deletions weren't the only change. There was also a change in the guidance about whether to report the arterial or venous code for graft or fistula PTA.

A closer look: The 35475/35476 edit becomes an issue when you must code for angioplasty of both the arterial and venous sides of the fistula because payers consider the arterial to the venous side to be a single vessel, and you may report only one PTA per vessel.

For example, Part B MAC NGS Medicare states the following in its local coverage determination (LCD) L30737:

• "For AV dialysis native fistulae, the 'vessel' is defined as the inflow artery at the AV anastomosis, the AV anastomosis, and the outflow vein to the level of the axillary vein."
• "For AV dialysis grafts, the 'vessel' is defined as the inflow artery at the arterial anastomosis, the arterial anastomosis, the entire length of the graft, the venous anastomosis, and the venous outflow to the level of the axillary vein."
• "All PTA done within these defined segments would be coded as a single angioplasty."

Change 2: "Guidance used to indicate that if arterial and venous sides of the fistula were plastied, to code it as a single venous structure. The latest guidance this year now recommends that if arterial and/or venous sides are both plastied to use the 35475 [arterial] angioplasty code," Midkiff says, citing the SIR 2010 Interventional Radiology Coding Users' Guide online supplement, page 11.

NGS Medicare reflects this change in its LCD: "If a PTA is performed at the arterial anastomosis of an AV dialysis access, it could be coded as 35475/75962 [Transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation].

In this instance, all PTA done within the AV dialysis access 'vessel' would still be coded as a single PTA but would be coded with the arterial codes (35475/75962) instead of the venous codes (35476/75978 [Transluminal balloon angioplasty, venous (e.g., subclavian stenosis), radiological supervision and interpretation]), and the venous codes would not be used for any other angioplasty performed within the AV dialysis access vessel."

Caution: You should not consider simple removal of the arterial plug during declot to be arterial PTA. That declot is part of thrombectomy.

Watch for Limited Circumstances to Report Both

The 35475/35476 edit has a modifier indicator of 1, which means you may override the edit with a modifier when appropriate.

Example: NGS Medicare article A49635 states that you may report the two together when the physician treats both of the following:

• an inflow vessel distinct from the "arterial anastomosis
• and peri-arterial anastomosis inflow" and
• "a stenosis within the access or central outflow veins."

But expect to provide documentation of anatomically separate lesions to prove medical necessity for reporting both codes.

CCI consideration: The column swap means that when you report the two codes together, you now should append modifier 59 (Distinct procedural service) to new column 2 code 35476.

But remember, the second PTA during the same session must be outside of the fistula. Payers consider the arterial and venous sides of the fistula to be a single vessel, so you should report that as a single PTA.