Cardiology Coding Alert

Love them or hate them, the trend toward guidance-inclusive codes doesn't seem to be slowing.

Case in point: CPT 2010 ousts 36145 (Introduction of needle or intracatheter; arteriovenous shunt created for dialysis [cannula, fistula, or graft]) and 75790(Angiography, arteriovenous shunt [e.g., dialysis patient], radiological supervision and interpretation) and instead instructs you to consider the following new surgical codes -- which include imaging:

• 36147 -- Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access of shunt, injection[s] of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava)

• +36148 -- ... additional access for therapeutic intervention (List separately in addition to code for primary procedure).

Proper use: If the initial evaluation (36147) prompts a therapeutic intervention requiring a second shunt catheterization, then report +36148 together with 36147, state CPT guidelines.

Remember that for add-on codes, such as +36148, the services "are always performed in addition to the primary service or procedure and must never be reported as a stand-alone code," says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting, a reimbursement consulting firm in Denver.

Fortunately, the 36147 descriptor is clear, and coding catheter placement with a diagnostic angiography should continue to be straightforward, says Kim French, CIRCC, director of interventional coding and reimburse-ment for a large physician group in Syracuse, N.Y. CPT's wording for +36148 also shouldn't lead to confusion, says French.

In 2009, you could report 36145 and 75790 together for catheter placement and diagnostic angiography. But CPT 2010 deletes 75790, and reporting 36147 covers both services.

These changes raise the question of when to use all new AV shunt angiography code 75791 (Angiography, arteriovenous shunt [e.g., dialysis patient fistula/graft], complete evaluation of dialysis access, including fluoroscopy, image documentation and report [includes injections of contrast and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior  vena cava], radiological supervision and interpretation).

Solution: Notes with 75791 tell you to use it only if the physician performs the radiological evaluation through an already existing shunt access or an access that isn't a direct shunt puncture. If the service requires catheter introduction, choose from 36140 (Introduction of needle or intracatheter ...), 36215-36217 (Selective catheter placement, arterial system ...), and 36245-36247 (Selective catheter placement, arterial system ...).

And to head off any confusion, notes instruct you not to report 75791 along with 36147/+36148.