General Surgery Coding Alert

Intervascular cannulization involves insertion of a flexible tube (a cannula) between two blood vessels, either vein to vein (36800, Insertion of cannula for hemodialysis, other purpose [separate procedure]; vein to vein) or artery to vein (36810, arteriovenous, external [Scribner type]). Arteriovenous shunts as described by 36810 may be referred to as Quintin, Dillard or loop shunts, as well. Such shunts (also sometimes called synthetic AV fistulae), which may be internal but are usually external, serve as a kind of "artificial" vein to allow repeated access for hemodialysis. Procedures 36800/36810 are less involved than insertion of a true AV fistula and heal more quickly, but are not as permanent and have a greater risk of failure and/or complications, Rasmussen says.

If complications occur, claim revision or closure of external revision of AV shunt using 36815 (... arteri-ovenous, external revision, or closure). To report removal of blood clots from such shunts, code either 36860 (External cannula declotting [separate procedure]; without balloon catheter) for incision or 36861 (... with balloon catheter) for use of a balloon catheter, as appropriate.

Surgeons normally place catheters for short-term use, such as while an AV fistula or intervascular cannula heals and/or develops, Rasmussen says. Catheters are prone to clogging, infection and other problems, but patients whose fistula or grafts are unsuccessful may need long-term catheter access. In such cases, the surgeon may tunnel the catheter under the skin to increase patient comfort and reduce the risk of complications.

Catheters used for hemodialysis consist of two lumens, or tubes, placed together. This allows the blood to leave the body through one lumen and return through the other. Depending on the catheter, the lumens may be fused together where they enter the body (thereby acting as a single, "double barrel" catheter) or enter the body side-by-side as two separate catheters.

Coding for such procedures is reported using 36488-36491, as appropriate, or 36533 (Insertion of implantable venous access device, with or without subcutaneous reservoir) for implanted catheters, as described in the September 2002 General Surgery Coding Alert. But when reporting twin catheters that do not enter the body as a single unit, you may claim placement of two catheters with either modifier -59 (Distinct procedural service) or -76 (Repeat procedure by same physician) appended to the second code, depending on payer preference (ask your payer for guidelines).

As an alternative, you may report one unit of the appropriate placement code with modifier -22 (Unusual procedural services) appended. If you choose the latter method, be sure to include a letter with the claim requesting an increase in reimbursement commensurate with the increased time and/or effort required to complete the procedure. In either case, be sure to provide a detailed operative report that precisely describes the nature of the procedure.

For example, the surgeon percutaneously places twin, fused catheters for hemodialysis in a 45-year-old male patient. Report the procedure 36489* (Placement of central venous catheter [subclavian, jugular, or other vein] [e.g., for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy]; percutaneous, over age 2). If the same surgeon places two, unjoined catheters for the same patient, report 36489, 36489-59 or 36489, 36489-76, depending on your payer's instructions. Or, you may report 36489-22.

Note: For more description and illustrations of the above types of venous access for dialysis, visit the National Kidney and Urologic Disease Clearinghouse Web site, www.niddk.nih.gov/health/kidney/pubs/vascular/vascular.htm.

In recent years, physicians have begun to use newer forms of vascular access that employ a subcutaneous implantable port and a double catheter system placed in the central veins, e.g., Life-site. The device uses a self-healing port that permits the dialysis needles to be inserted in the same place every treatment. The catheters are intended for long-term use and are generally tunneled. As such, placement of the catheters should be reported using 36533. Again, because the surgeon must place two separate catheters, you may claim two units of 36533, appending either modifier -59 or -76, as requested by the payer. Because this is a new technology, however, you should contact your carrier prior to coding to see if it has special instructions or requirements.