Radiology Coding Alert

Define peripheral/central circuit and look for thrombectomy/thrombolysis services.

Effective Jan. 1, 2017, you will need to update your dialysis circuit procedure codes. CPT^®  2017 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 …), which 2016 provides for evaluation via an existing shunt access or via access not involving a direct puncture of the shunt.

What is new? You have nine new codes to add to your list. Besides, the new codes, you have revision in guidelines too.

The American College of Radiology (ACR) has published a listing of 2017 updates which also lists the new dialysis procedure codes. You can access the ACR guidance on: http://www.acr.org/~/media/ACR/Documents/PDF/Economics/CPT 2017 Code Update FINAL 10_20_16updated.pdf.

Here are five key steps to help you prepare for the fast approaching change.

1. Begin with Access Code 36901

For direct access and imaging of the entire dialysis circuit, you should submit code 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). Your radiologist may perform antegrade and/or retrograde punctures in the dialysis circuit and also inject contrast, if needed, for the purpose of imaging.

Path of catheter is not important: During the diagnostic imaging of the dialysis circuit, your physician may advance the catheter further into the circuit. Any such movements of the catheter are inclusive in code 36901. Below are the services that are inclusive in code 36901:

• Advancement of catheter to view arterial anastomosis
• Selective catheterization of venous branch, if needed
• Advancement of catheter to vena cava
• Evaluation of peri-anastamostic portion of inflow

Modifier 52:  In cases where a physician performs radiological supervision and interpretation of angiography through an existing access or catheter-based arterial access, you should append modifier 52 (Reduced services) to 36901.

2. Note Two Codes for Peripheral Segment Angioplasty

Here are two codes for angioplasty in the peripheral dialysis segment:

• Code for peripheral angioplasty: 36902, …with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty
• Code for 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.

Note: Codes 36902 and 36903 apply to the “peripheral dialysis segment.”

3. Check Add-On Codes For Central Segment Imaging

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:

• Code for 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)
• Code for 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).

Tip: Use these codes for procedures 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.

Go beyond 36901-36906 for primary codes: As implied, 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.

4. Target Three New Codes for Thrombectomy/Thrombolysis

When your physician performs thrombectomy or thrombolysis, you should consider the following three discrete codes for these services:

• Code for 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)
• Code with peripheral angioplasty: 36905, … with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty
• Code 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.

Caution: CPT^® does not allow reporting a code from 36904-36906 together with a code from 36901-36903. Whenever the procedure includes thrombectomy, thrombolysis, or both, be sure you choose the required code from 36904-36906 based on the highest level of service performed.

5. Focus on +36909 for Embolization/Occlusion

The final new code is also an add-on code for embolization or occlusion of the dialysis circuit. It is +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]).

Never miss the primary code: The appropriate primary codes for +36909 are 36901-36906.

Final note for the rare ultrasound guidance: You may report +76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real time ultrasound visualization of vascular needle entry, with permanent recording and reporting [List separately in addition to code for primary procedure]) with these dialysis circuit codes. However, use of ultrasound guidance for these dialysis segment procedures is rather rare. Note: Physicians most often use ultrasound for new or failing arteriovenous fistulas (AVFs).