Radiology Coding Alert

Question: A patient has thrombosis of the Perma-cath for dialysis. Contrast was injected into the Perma-cath, both arterial and venous routes, and showed partial thrombosis. Tissue plasminogen activator (TPA) solution was administered into both arterial and venous routes. After completion of the injection, contrast material was injected and complete thrombolysis of the clot was established through both routes. How should I code this procedure?

Iowa Subscriber

Answer: There are two distinct steps (diagnostic and therapeutic) to the procedure conducted in this case, and each may be coded to reflect the work performed.

The initial percutaneous study diagnosing the thrombosis would be reported with 36145 (introduction of needle or intracatheter; arteriovenous shunt created for dialysis [cannula, fistula, or graft]). Because you report that two access procedures were used, code 36145 should be used twice. The radiological supervision and interpretation (RS&I) code 75790 (angiography, arteriovenous shunt [e.g., dialysis patient], radiological supervision and interpretation) is used once to describe all of the diagnostic angiography performed prior to, during and after the intervention.

The therapeutic thrombolysis with TPA would be billed with G0159 (percutaneous thrombectomy and/or revision, arteriovenous fistula, autogenous or nonautogenous dialysis graft) to describe all percutaneous methods of opening thrombosed dialysis shunts, including mechanical thrombectomy, Fogarty balloon and administration of a thrombolytic agent. More prolonged infusions may be coded with 37201 (transcatheter therapy, infusion for thrombolysis other than coronary), although these longer infusions would be rather unusual in this clinical setting. Because the same access is used for both the diagnostic and therapeutic services, there would be no additional surgical codes for this portion of the procedure. Similarly, the previously reported 75790 includes all angiography before, during and after the intervention. Consequently, there would be no additional RS&I codes used. Additional codes would be engendered by further interventions such as angioplasties or stent placements.

This coding strategy is pertinent to Medicare patients only. Because Medicare covers the vast majority of dialysis patients, however, this should suffice for most instances. For those rare circumstances when the patient is covered by another insurance company, the coding strategy should be confirmed with that particular insurer.