Radiology Coding Alert

 Our experts help you through the ins and outs of this coding conundrum

Scenario: A physician's report states that a patient presented with a central venous device obstructed by a fibrin sheath. The physician stripped the fibrin sheath mechanically, through a separate incision, under imaging guidance. 
 
Recognize the procedure: Venous access devices, used to aid in procedures such as dialysis and chemotherapy, can become obstructed when fibrin or thrombus collect at the end of the device or within it. Mechanically removing the fibrin sheath prevents the physician from having to remove the old device and insert a new one. 
 
ICD-9 Codes insight: The diagnosis code for this procedure is 996.74 (Other complications of internal [biological] [synthetic] prosthetic device, implant, and graft; due to other vascular device, implant, and graft), says Donna J. Richmond, CPC, RCC, a coder with radiology expertise at CodeRyte Inc.
 
CPT choice: "Mechanical removal of obstructed material is code 36595 if done through a separate incision," says Kathy Lyons, RN, administrator at the Park Cardiothoracic and Vascular Institute in Jefferson Borough, Pa. Code 36595 (Mechanical removal of pericatheter obstructive material [e.g., fibrin sheath] from central venous device via separate venous access) is a surgery/cardiovascular system code.
 
Report code 36595 in conjunction with radiology code 75901 (Mechanical removal of pericatheter obstructive material [e.g., fibrin sheath] from central venous device via separate venous access, radiologic supervision and interpretation), Richmond says. These two codes indicate that the physician mechanically stripped the fibrin sheath occluding the catheter.
 
Watch for: Code 36596 (Mechanical removal of intraluminal [intracatheter] obstructive material from central venous device through device lumen) may seem similar to 36595, but don't get the two confused. "Code 36596 is the mechanical removal of intraluminal obstructive material from a central venous line if done through the lumen of the central device," Lyons says. This code would be used, for example, if a guidewire were used to loosen and then aspirate the obstruction.   
 
If you do have a report that says a radiologist used imaging guidance for a procedure you code as 36596, don't forget to include 75902 (Mechanical removal of intraluminal [intracatheter] obstructive material from central venous device through device lumen, radiologic supervision and interpretation), Richmond says. CPT Guidelines direct you to report both codes when the documentation indicates imaging guidance.
 
Note: You can't report 36550 (Declotting by thrombolytic agent of implanted vascular access device or catheter) in addition to either 36595 or 36596. "Code 36550 is just for injecting a thrombolytic (tPA) within the catheter to dissolve a clot," Richmond says. "Code 36550 has no physician work RVUs [relative value units] because it's usually done by staff."