Radiology Coding Alert

Bolster your interventional coding with this thrombectomy example

"Thorough" is the name of the game when it comes to IR coding. We'll walk you step by step through this complicated scenario to make sure you don't miss any opportunity for reimbursement.
 
The first step: Put your interventional radiology (IR) skills to the test with this clinical example of a clotted AV (arteriovenous) graft provided by Deepa Malhotra, CPC, president of Healthcare Educational Resource Services (HERS Inc.) in Chicago.

Procedure performed: tPA, angioplasty, and thrombectomy.
 
Patient was brought to the angiogram suite and put in a supine position. Left arm was prepped and draped in sterile fashion. Skin was infiltered with 2 percent lidocaine. 18 gauge angiocath was inserted into the graft. 2,500 units of heparin was injected. 20,000 units of urokinase was infused for an hour. Guide wire was passed through, and a 7 French sheath was placed. Graft-venous anastomosis was crossed, and central veins were evaluated. Left axillary vein, subclavian vein, innominate vein and SVC are patent and unremarkable. Graft-venous anastomosis is to the antecubital vein. The main draining veins are the left basilic and brachial veins. Left cephalic vein occludes about 2 inches above the elbow joint. Graft-venous anastomosis is mildly stenotic. There are multiple severe intragraft stenoses. Graft venous anastomosis and intragraft stenoses were dilated with 6-mm and 7-mm balloon.
 
Since there is no flow in the graft, puncture was made in the graft toward the arterial end. Arterial anastomosis was crossed with a Benston wire, and a 6 French was placed. Using a 5 French over the wire, Fogarty balloon arterial plug was removed. Subsequent venogram shows multiple filling defects through the graft, which were then removed using Teratola Basket. Postprocedure venogram shows good flow through
the graft.

Challenge Yourself to Find All the Codes

What to do: Whenever you have a procedure like this, start by confirming that it actually took place within a dialysis graft, says Donna Richmond, CPC, RCC, a radiology coding expert with CodeRyte Inc.
 
And pay particular attention to when the report says "injection" or "infusion" to be sure you correctly identify the procedure, Malhotra says.
 
Once you know this, you can be sure 36145 (Introduction of needle or intracatheter; arteriovenous shunt created for dialysis [cannula, fistula, or graft]) is the right code for the inserted angiocatheter, Malhotra says. But don't report separate codes for the injection of heparin or infusion of urokinase, she says.
 
Instead, your next code will be an S&I code for the shunt evaluation (75790, Angiography, arteriovenous shunt [e.g., dialysis patient], radiological supervision and interpretation).
 
Watch for: Code 75790 includes all imaging of the graft and venous outflow, says Danette Jones, CPC, RCC, CIC, with Central Kentucky Radiology. Don't forget: For physician coding, add modifier -26 (Professional component) to your S&I code.
 
For the balloon dilation (PTA, percutaneous transluminal balloon angioplasty), report both 35476 (Transluminal balloon angioplasty, percutaneous; venous) and 75978 (Transluminal balloon angioplasty, venous [e.g., subclavian stenosis], radiological supervision and interpretation), Richmond says. Again, append modifier  -26 to your S&I code if you're coding for physicians.
 
This code pair takes care of the angioplasty within the graft and also at the graft-venous anastomosis, Malhotra says.
 
Rule of thumb: Code just once for any and all angioplasty within the graft, at either/both anastomoses, and within the draining veins, Richmond says. But if another PTA is performed at the subclavian vein, you can report 35476 and 75978 again, she says.
 
Don't miss: You can report 36145 twice if the graft is accessed twice, Jones says.
 
Depending on your payer, you may need to report 2 for your "number of services" or report 36145, 36145-59 (Distinct procedural service) to indicate the graft access at the arterial end and the venous end.
 
Next step: Report 36870 (Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft [includes mechanical thrombus extraction and intra-graft thrombolysis]) for all of the declotting procedures documented in the report, Malhotra says. This includes lysis and mechanical removal.
 
Hidden trap: Code 36870 covers quite a few services: the urokinase infusion within the graft, removal of the clots within the graft using the Teratola Basket, the use of the Fogarty Balloon to remove the arterial plug, and the postprocedure venogram, Malhotra says.