General Surgery Coding Alert

Don’t get lost in complete coding overhaul.

If your general surgeons perform dialysis access and management procedures, you need to get on board with massive changes in CPT® 2017.

Study our five expert tips to help you make sense of the nine new codes, two full pages of guidelines, and must-read code-level notes that will drive your coding for these procedures.

Tip 1. Make Room for 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 …) that you formerly used to evaluate the arteriovenous dialysis circuit via an existing shunt, or at least not involving a direct shunt puncture.

Tip 2. Focus on First Three New Codes Absent Thrombectomy

The first three new codes break down this way, with a comprehensive approach that includes 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).

Understand hierarchy: 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 “Study New Guidelines to Discover Dialysis Circuit Designations” for more on what those terms mean.

Tip 3. Consider These Codes for Thrombectomy/Thrombolysis

The next three codes have a progressive hierarchy structure similar to 36901-36903, combining various services and building from a main code. However, these codes focus on thrombectomy/thrombolysis, and then offer 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.

Tip 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 surgeon 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.

Tip 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.