Part B Insider (Multispecialty) Coding Alert

Question: How can we code for AV dialysis graft imaging and embolization?

The procedure note reads as follows:

“After informed consent was obtained, the patient was brought into the operating room and was placed in supine position. After padding all bony prominences, the left arm was extended 90 degrees from the patient’s side. The region over the distal fistula was anesthetized. We then accessed the fistula using a micropuncture needle and placed a micropuncture wire which was threaded with a micropuncture sheath. A fistulogram was performed and it revealed a large side branch. This side branch was coil embolized. The size of the coil used was 3 mm. we then repeated the fistulogram and this showed complete flow to the central venous system. Manual pressure was then applied over the access site and the procedure was completed. The patient has normal vitals and was in stable condition.”

Answer: From the procedure described, it is clear that your physician has tried to gain a direct access into the distal part of the fistula for a fistulogram. However, you will not report code 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]) for this procedure, though the code is inclusive of both access and imaging.

Your physician also does embolization of the side venous branch. You should report for the selective catheter placement for selection of the venous branch. This changes the scenario of coding for the procedure.

Due to the selective catheter placement, you will replace code 36147 with 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). This is because code 36147 includes non-selective access which is bundled into the selective catheter placement.

For catheter placement in the side branch, you should submit code 36011 (Selective catheter placement, venous system; first order branch [e.g., renal vein, jugular vein]) as this is a first order selective catheterization.

You should report code 37241 (Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage [e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles]) for embolization of the venous collateral branch.