Part B Insider (Multispecialty) Coding Alert

Reporting 75790 for shunt evaluation goes the way of the dodo in a few weeks.

If you've noticed a trend toward guidance-inclusive procedure codes, you're right. Along those lines, CPT 2010 adds AV shunt cath placement and angiography to that growing list.

Keep in mind: The code changes are effective Jan. 1, so take steps now to be sure you're ready to apply the new codes from day one.

CPT 2010 ousts 2009 codes 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.

Crucial: These new codes 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).

Code +36148 is like all add-on codes. "These services are always performed in addition to the primary service or procedure and must never be reported as a standalone code," says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting, a reimbursement consulting firm in Denver.

What to do: Report +36148 together with 36147 if the initial evaluation (36147) prompts a therapeutic intervention requiring a second shunt catheterization (+36148), state CPT guidelines.

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 reimbursement Crouse Radiology Associates in Syracuse, N.Y. CPT's wording for +36148 also shouldn't cause confusion, says French.

Avoid Misguided Guidance Coding

In 2009, you could report 36145 and 75790 together for catheter placement and diagnostic angiography. But CPT 2010 deletes 75790, and reporting new code 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 the code 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 just to be extra clear, notes instruct you not to report 75791 along with 36147/+36148.

Prediction: The CPT committee will continue to look at codes that are performed together by the same physician on the same day of service 95 percent of the time, said Barbara S. Levy, MD, AMA/Specialty Society Relative Value Scale Update Committee (RUC) chair, at the AMA's CPT and RBRVS 2010 Annual Symposium in Chicago.