Cardiology Coding Alert

Study the guidelines to discover lower extremity dialysis circuit definitions.

It’s a good thing there’s some time to prepare for the new dialysis circuit codes going into effect Jan. 1, 2017. With nine new codes, two full pages of guidelines, and must-read code-level notes, that time will come in handy for getting to know the changes. If you code for these services, six steps will help you identify the areas where you’ll need to focus your update preparations.

1. Make Room for the New Codes With These Deletions

As part of the 2017 update, CPT^® deletes dialysis shunt codes 36147- +36148 (Introduction of needle and/or catheter, arteriovenous shunt created for dialysis [graft/fistula] …).

CPT^® 2017 also deletes S&I code 75791 (Angiography, arteriovenous shunt …), which 2016 provides for evaluation via an existing shunt access or via access not involving a direct puncture of the shunt.

2. Focus on the First Three Codes When Thrombectomy Is Absent

The first three new codes break down this way, with a comprehensive approach that bundles in a variety of services:

• Needle/cath introduction: 36901, Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report
• With peripheral angioplasty: 36902, …with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty
• With peripheral angioplasty and stent(s): 36903, … 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.

These codes are similar to the typical progressive hierarchy you are familiar with, where you choose one code from the group based on the highest level of service performed. For example, if the physician performs angiography, angioplasty, and stenting in the peripheral segment, you’ll report only 36903 to represent all three services. You should not report 36901, 36902, and 36903 together.

Important: Codes 36902 and 36903 apply to the “peripheral dialysis segment.” CPT^® 2017 introduces other new codes, +36907 and +36908, specific to the “central dialysis segment.” See Step 6 for more on what those terms mean.

If the physician performs thrombectomy or thrombolysis, you should consider the next three codes instead.

3. Think Through Your Thrombectomy/Thrombolysis Options

The next three codes have a progressive hierarchy structure similar to 36901-36903, combining various services and building from a main code, this time focused on thrombectomy/thrombolysis, and then offering comprehensive angioplasty and stent options for the peripheral dialysis segment:

• Thrombectomy/thrombolysis: 36904, 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 peripheral angioplasty: 36905, … with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty
• With peripheral angioplasty and stent(s): 36906, … 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 circuit.

CPT^® warns you away from reporting a code from 36904-36906 together with a code from 36901-36903, so if the encounter includes thrombectomy, thrombolysis, or both, be sure you choose your code from 36904-36906 based on the highest level of service performed.

Key point: Removal of the arterial plug using a balloon catheter to mechanically dislodge a thrombus, even a resistant thrombus, is not an angioplasty. Fistula thrombectomy includes that arterial plug removal. The physician’s documentation should specify the intent of the service, notes Christina Neighbors, MA, CPC, CCC, coding quality auditor for Conifer Health Solutions.

4. See How Central Segment Changes Coding

You’ve now seen codes for angioplasty and stenting in a peripheral dialysis segment. The next two codes are add-on options for when those interventions are in the central dialysis segment:

• With central angioplasty: +36907, 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)
• With central angioplasty and stent(s): +36908, Transcatheter placement of 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).

These central segment codes have a progressive hierarchy of their own. Code +36907 covers angioplasty, and +36908 covers both angioplasty and stenting.

Tip: Use these codes for procedures the cardiologist performs through a puncture in the dialysis circuit. If the physician uses a different access, then you’ll need a different code, such as 37238-+37239 for venous stent placement or new codes 37248-+37249 for venous angioplasty.

As you might expect, the primary codes for +36907 and +36908 include 36901-36906. But 36818-36833, which include services such as open arteriovenous graft creation and thrombectomy, are also appropriate primary codes according to CPT^® guidelines.

5. Count to 1 for Embolization/Occlusion Code

The final new code is also an add-on code: +36909 (Dialysis circuit permanent vascular embolization or occlusion [including main circuit or any accessory veins], endovascular, including all imaging and radiological supervision and interpretation necessary to complete the intervention [List separately in addition to code for primary procedure]).

You’ll use this code once per session regardless of the number of branches involved. The appropriate primary codes for +36909 are 36901-36906.

6. Accept That Studying the Guidelines Is a Must

The two pages of guidelines for the new codes are similar to the guidelines you already know for dialysis circuit services, but there are some changes. Each code has code-level notes, too. With so many instructions, a refresher on all the rules, even ones that aren’t new, is a good idea.

In the guidelines, you’ll find definitions of the peripheral segment and central segment. These definitions are a lot like what you find in the CPT^® 2016 guidelines, but add helpful information on lower extremity dialysis circuits as well as upper extremity.

Lower: For a lower extremity circuit, CPT^® defines the peripheral segment as extending through the femoral vein. The central dialysis segment includes veins central to the common femoral. CPT^® lists the external and common iliac veins through the inferior vena cava (IVC).

Upper: For an upper extremity circuit, the peripheral segment extends through the axillary vein or the cephalic vein if the patient has cephalic vein outflow. The upper extremity central segment involves the veins that are central to the axillary and cephalic veins. CPT^® names the subclavian and innominate (brachiocephalic) veins through the superior vena cava.

Peripheral hint: CPT^® includes the area around the anastomosis, including a short part of the parent artery and a short part of the circuit near the anastomosis, in the peripheral segment. CPT^® 2017 terms this area the “historic peri-anastomotic region.”

Unusual cases: Here are some of the other highlights to watch for as you read (and reread) the updated guidelines:

• Ultrasound: You may report +76937 (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]) with these dialysis circuit codes, but it should be rare. You may see ultrasound required most often for new or failing arteriovenous fistulas (AVFs).
• S&I: In cases where a physician performs radiological supervision and interpretation of angiography through an existing access or catheter-based arterial access, you should append modifier 52 (Reduced services) to 36901.

Final tip: When dealing with major changes like this, Neighbors advises reviewing the updated codes, researching guidelines, taking notes, and even practice using the new codes on current cases (not to submit, of course) to get familiar with the changes before they go into effect.