Radiology Coding Alert

Watch for 2 separately reportable services.

Flip through the Surgery section of your 2012 CPT® manual, and you'll find more than a page of new guidelines for arteriovenous (AV) shunts. Here are the highlights so you can properly apply the rules to your claims.

Start here: The new guidelines help clarify proper reporting for 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]), explained Sean P. Roddy, MD, of the CPT® Advisory Committee and Society for Vascular Surgery, in his CPT® and RBRVS 2012 Annual Symposium presentation.

The guidelines for AV shunts for dialysis feature one section for diagnostic studies and one section for interventions. This article will focus on the diagnostic study guidelines, which detail (1) which services are included in 36147 and (2) which services you may report in addition to 36147 when performed. Watch for a future issue to cover the intervention guidelines.

1. Steer Clear of These Included Services

The guidelines point out that 36147 includes the services described below, Roddy noted. You should not report a separate code for these services.

Access/imaging: The work of directly accessing and imaging the entire AV shunt is included in 36147. Per the guidelines, the puncture may be antegrade or retrograde, and the physician may inject the contrast through a needle or catheter.

Cath manipulation: Catheter advancement in the shunt and/or vena cava is included. The guidelines specify that 36147 includes all manipulation for diagnostic imaging of the shunt.

Here's what that means for you:

• You should not code separately for either advancing the catheter to the vena cava or advancing the catheter through the arterial anastomosis when done to visualize the shunt or the anastomosis, which is the surgical connection between the two vessels (see "36147: Get a Better Picture of Fistula Vs. Graft" on page 29 for more information).
• Similarly, the guidelines specify that 36147 includes evaluating the part of the inflow vessel near the surgical opening. The guidelines refer to this as the peri-anastomotic portion of the inflow. Peri- means near or around, so peri-anastomotic means the portion near or around the surgical connection between the two vessels.

2. Capture These 2 Separately Reportable Services

There are services CPT® says you may report in addition to 36147, Roddy said. These relate to ultrasound guidance and arterial inflow selective catheterization.

US guidance: Assuming the documentation is sufficient, CPT® states you may report ultrasound guidance for puncture of the AV shunt using +76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting [List separately in addition to code for primary procedure]).

Keep in mind that reporting ultrasound with 36147 should not be standard procedure. The physician should describe the medical necessity for its use in the patient's case. Additionally, CPT® guidelines for ultrasound guidance "require permanently recorded images of the site to be localized, as well as a documented description of the localization process, either separately or within the report of the procedure for which the guidance is utilized."

Arterial inflow cath: You may report selective catheterization of the arterial inflow from the AV shunt puncture separately. This is allowed because CPT® considers the arterial inflow to be a separate vessel from the shunt. Guideline: Separate coding is appropriate when the physician suspects a problem separate from the peri-anastomotic segment and that's why he advances the catheter into the artery and performs imaging. (In other words, advancing the catheter into the artery just to get a better look at the anastomosis or shunt is included in 36147.)

For the catheterization, 36215 (Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family) is often appropriate. In this context, the code includes cath placement into the aorta. You should not additionally report 36200 (Introduction of catheter, aorta) for this service, Roddy said. As the guidelines explain, 36200 work is included in 36215.