Coding of Procedures in Interventional Nephrology: Overview of changes in the 2010 revision

Vessel Definitions

Central versus Peripheral

• The anatomy texts do not contain a definition of central and peripheral veins

• Central veins– Upper - Veins within the boney thorax– Lower – Veins within the boney pelvis

• Peripheral veins– Veins of extremity up to central veins

Definition of Access

• The vascular access is considered to be a separate vessel by definition

• It extends from the arterial anastomosis through to the beginning of the central veins, i.e., the subclavian

• The arterial anastomosis with the adjacent 2 cm of artery is defined as the arterial portion of the access

• The entire remainder of the access is defined as the venous portion for coding purposes

Coding Changes for 2010

• New codes• 36147 – Cannulation and access angiogram• 36148 – Second cannulation for therapeutic purposes• 75791 – Angiogram of access without cannulation

• Code deletions• G0392 – Arterial angioplasty within access• G0393– Venous angioplasty within access• 36145 – Non-selective cannulation• 75790 – Angiogram of access

Coding Access Angioplasty

New Policy Guidelines

• In 2006 CMS issued two new G codes take effect on January 1, 2007– Venous angioplasty – G0393– Arterial angioplasty – G0392

• These have been discontinued, we are to back to using the old standard codes– Venous angioplasty – 35476 – Arterial angioplasty - 35475

Potential Confusion

• There are special regulations that relate to angioplasty within the access

However• 35475 and 35476 must be used for all angioplasty

both outside of and within the access

• Good documentation is important

Multiple Angioplasties

Within the Access

• Situations in which multiple angioplasties may be coded are very limited

• Although multiple lesions may be present within the access one is permitted to use only a single code

• If these multiple treatments within the access are all venous, then a single venous angioplasty code, 35476, should be used

• If both an arterial angioplasty (arterial anastomosis) and a venous angioplasty are performed within the access, only the arterial treatment should be coded using 35475

Vessels Outside the Access• Any lesion present within a distinctly separate central venous

structure, warrants a separate code - 35476 • Treatment of a lesion within a distinctly separate feeding artery

warrants a separate code - 35475 • A separate supervision and interpretation code, 75978 (for venous)

or 75962 (for arterial), should be paired with each of the angioplasty codes

• The second venous (within the central veins) or arterial angioplasty (within the feeding arteries) should have a -59 modifier attached as should the second venous S&I code

• The second arterial angioplasty has a different S&I code, 75964

Coding Multiple Angioplasties• No more than two angioplasty codes should be used in any case• This could be

– one arterial (for the anastomosis or a feeding artery) and one venous (for a central venous lesion)

– two venous - one in the access and one central– two central and none in the access– Two arterial (the anastomosis and a feeding artery, or two feeding

artery)• Any time two angioplasty codes are used very good

documentation should be supplied to explanation the rational for the two codes

Contiguous Lesions

• If a single lesion extends across two adjacent separate vessels, treatment warrants only a single angioplasty code

• In instances in which the exact anatomical identity of the vessel is critical for coding purposes, a lesion that bridges across two vessels should be defined by the vessel in which it lies predominantly

• Two codes are warranted only in instances in which separate distinct lesions are present in separate vessels, provided that the two vessels qualify for separate coding based upon the access versus central veins rule as described

Changes In Cannulation Codes

Basics• Cannulation or catheterization may be either selective or non-selective• Selective cannulation is a column 1 code and non-selective is a column

2 and these two codes are mutually exclusive• The most frequently performed cannulation is non-selective• The target vessel is entered directly and no further manipulation is

required• This cannulation can be performed under two circumstances –

– Non-selective cannulation to perform an angiogram of the access– Non-selective cannulation for a therapeutic intervention

• With the new regulations, these two procedure types should be coded differently

Non-selective cannulation for purposes of an access angiogram

• The code 36147 is a new code for 2010• This code bundles an angiogram of the access with a

non-selective cannulation performed for the purpose of performing the study

• This code is specific for the dialysis access (either fistula or graft)

• Not an appropriate code for use when a vein is cannulated as for vein mapping

• 36145 and 75790 have now been discontinued

Non-selective cannulation for therapeutic purposes

• If a non-selective cannulation of the access is performed for the purpose of performing a therapeutic intervention, another new code, 36148, should be used

• This would be used for the second cannulation done for a thrombectomy, for example

Selective catheterization (cannulation)• A selective catheterization code cannot be used with a nonselective

code for the same site• The selective code should be treated as a column 1 code and the

nonselective as a column 2 code and the two are mutually exclusive• Two situations:

– Only one non-selective cannulation – list only the angiogram (discussed further below)

– A second nonselective cannulation is performed - this should be dropped in favor of selective code

• The basic principle is - each time a site is used for a selective catheterization, a non-selective code is dropped in favor of the selective one

Restrictions On Selective Catheterization

• Only selective catheterization of a first or second order artery is allowed– 36215 & 36126 (36245 in lower extremity)

• Selective catheterization of venous side branches is considered to be bundled with 36147– 36011 & 36012 can not be used

Angiogram of Access

• An angiogram of the access can actually be coded three different ways depending upon the individual situation:– Angiogram performed with cannulation – Angiogram only• Angiogram performed through a pre-existing cannulation of

access • Separate angiogram of access code without a cannulation code

– Separate coding of angiogram components

Angiogram Performed With Cannulation

• Already discussed on slide 16• The code 36147 bundles an angiogram of the access

with a non-selective cannulation performed for the purpose of performing the study

• This code is specific for the dialysis access (either fistula or graft)

• All catheter insertion and manipulation within the access is bundled except as listed for selective catheterization of an artery

Codes Bundled With 36147• 36145 – Cannulation of access• 75790 - Angiogram of access • 76000 - Fluoroscopy (separate procedure) up to one hour

physician time• 75820 - Venography, extremity, unilateral• 75825 - Venography, caval, inferior, with serialography • 75827 - Venography, caval, superior, with serialography• 36140 – Cannulation of extremity artery (excludes brachial)• 36010 – Selective catheterization of superior or inferior vena cava

Angiogram Only

• 75791 should be used for an access angiogram when a cannulation is not performed

• This code should not be used except where the angiogram is being coded without an accompanying non-selective cannulation– Angiogram performed through a pre-existing cannulation

of access – Separate angiogram of access code without a cannulation

code

Angiogram performed through a pre-existing cannulation of access

• Occasionally the patient presents to the angiography suite with a needle or catheter already in place.

• In this instance, the access does not require cannulation in order to perform the angiogram.

• In this instance the code 75791 would be used for the procedure.

Separate angiogram of access code without cannulation code

• How can the cannulation code in the 36147 bundle be dropped while maintaining the angiogram coding

• This should be done by listing the angiogram as a separate study using the code 75791

• If a second cannulation for therapeutic purpose, code 36148, has been the site of the selective catheterization, it would simply be dropped in favor of the selective code

• Remember that neither 36147 nor 36148 can be used together with 75791

Separate coding of angiogram components

• In order to qualify as a separate procedure and be coded separately, the angiogram must be performed by cannulating a separate site, a site that is not part of the access as defined

• 75820 or 75827, should be listed with a -59 modifier• In this setting 36147 should not be coded (no

reason)• A cannulation for therapeutic purposes may be done

SUMMARY AND CONCLUSIONS

• New regulations have been scheduled to begin January 1, 2010

• Important that the interventionalist dealing with dialysis access procedures become familiar with these and become accustomed to their application

• As is always the case there is very likely to be confusion initially before the changes become infused throughout the system

• A complete copy of the new manual may be obtained from the “Members Only” websites of either ASDIN or RPA

• Use of uniform coding practices and consistently following a set of standardized recommendations such as those represented in the Coding Manual is very important

• It is only by doing this that our Society will be able to speak in the future with a strong, unified voice in matters that relate to this very important aspect of our rapidly growing field

Illustrative Cases for Coding

Tunneled Catheter Placement

There are no changes in coding in this category of procedures

Angioplasty of Venous Stenosis

Uncomplicated

History

• 64 year old male• Polycystic kidney disease• Dialysis for 5 years• Loop graft in left arm• Referred for low flow

Physical Examination

• Loop graft in left forearm• Hyper-pulsatile• Augmented well• Prominent thrill at venous anastomosis• High pitched bruit at venous anastomosis, diastolic

component diminished

Stenosis at anastomosis

Draining veins normal

Central veins normal

SVC normal

Graft, anastomosis and artery - normal

Angioplasty performed

Results of treatment

Coding of Case

2009• 36145 - Cannulation• 75790 - Angiogram of access • G0393 - Venous angioplasty • 75978 - S & I for G0393

2010• 36147 - Cannulation with

angiogram • 35476 – Venous angioplasty• 75978 – S&I for 35476

Angioplasty

Venous and arterial problem

History

• 48 year old male• On hemodialysis for 3 years• Left forearm loop graft• Has 10% recirculation• Poor flow

Examination

• Left forearm loop graft• Augments poorly• Thrill at venous anastomosis

Stenosis at venous anastomosis

Cephalic normal

Central veins normal

Angioplasty done with 8 X 4 balloon

Lesion dilated completely with no residual

Stenosis of arterial anastomosis

Next Step

• Graft cannulated second time on arterial side

• Arterial anastomosis dilated with 6 X 4 balloon

Post angioplasty

Coding of Case

2009• 36145 - Cannulation of graft • 75790 - Angiogram of graft • 36145-59 - 2nd cannulation • G0393 , 75978 - Venous

angioplasty • G0392 , 75962 - Arterial

angioplasty • 74710 - Arteriogram

2010• 36147 – Cannulation and access

angiogram• 36148 – Second cannulation for

therapeutic purposes• 35475 , 75962 - Arterial

angioplasty • 74710 - Arteriogram

Graft With Poor Flow

Venous angioplasties and SVC angiogram

History

• 50 year old male with forearm loop graft• Referred for decreased flow• Has had previous central venous catheters

Physical Examination

• Graft was hyper-pulsatile• Collateral veins on upper arm and chest

Anastomosis stenosis

Basilic stenosis

Brachiocephalic vein stenosis

Next Step

• After multiple attempts, a guidewire was passed across the innominate lesion

• A catheter was passed across the lesion • Superior vena cava angiogram and angiogram of

central veins was performed through catheter

Central veins and SVC angiogram

Basilic angioplasty with 8 X 4

Anastomosis angioplasty with 8 X 4

Angioplasty with 12 X 4

Post treatment result

Inflow Evaluation

• The flow in the graft as tested with a bolus of radiocontrast appeared to be excellent

• The graft augmented well

• Conclusion good inflow

Arterial anastomosis

Coding of Case

2009• 36010 - Selective catheterization

of SVC • 75790 - Angiogram of graft • 75827-59 - Angiogram of SVC • G0393, 75978 - Venous

angioplasty • G0393 -59, 75978-59 - 2nd venous

angioplasty • 35476 , 75978 - 3rd venous

angioplasty

2010• 36147 - Cannulation and access

angiogram• 35476 , 75978 - Venous

angioplasty • 35476 -59, 75978-59 - 2nd

venous angioplasty

Thrombectomy

Arterial embolus

History

• The patient is a 47 year old male• Left upper arm straight graft• Referred for thrombectomy

Stenosis of anastomosis

• Thrombectomy done in standard manner• No difficulties encountered initially• With use of Fogarty patient began to appear

uncomfortable• Examination revealed that hand was cold and the

radial pulse that had been present earlier was now gone

Arteriogram

Done via catheter inserted into brachial artery – selective catheterization

Arterial Embolectomy

Coding of Case

2009• 36145 - Cannulation • 75790 Angiogram of graft • 36870 - Thrombectomy • G0393 , 75978 - Venous

angioplasty • 36215 - Selective catheterization

of 1st order artery • 75710 - Arteriogram • 37186-59 - Embolectomy,

brachial

2010• 36147 – Cannulation and access

angiogram• 36870 - Thrombectomy • 35476, 75978 - Venous

angioplasty • 36215 - Selective catheterization

of 1st order artery • 75710 - Arteriogram • 37186-59 - Embolectomy,

brachial

Poor Flow in Fistula

Juxta-Anastomotic Stenosis

History

• 48 year old male• Radial-cephalic fistula• Fistula is 2 years old• History of difficult cannulation• Poor flow

Physical Examination

• Radial-cephalic fistula in right arm• Poorly palpable in upper portion• Did not augment very well• Apparent juxta-anastomotic stenosis

Initial Angiogram

Angioplasty #1

Angioplasty #2

Post - angioplasty

Coding of Case

2009• 75790 - Angiogram of fistula • G0392 , 75962 - Arterial

angioplasty • G0393 , 75978 - Venous

angioplasty • 36215 – selective

catheterization of 1st order artery

• 75710 - Arteriogram of extremity

2010• Angiogram of access without

cannulation - 75791• 35475, 75962 – Arterial

angioplasty• 36215 – selective

catheterization of 1st order artery

• 75710 - Arteriogram of extremity

Poor Development of Fistula

Accessory vein

History

• 32 year old male• Fistula created 6 months earlier• Fistula used for two months• Very difficult to cannulate

Physical Examination

• Radial-cephalic fistula– High anastomosis

• Strong thrill at anastomosis• Fistula not palpable above mid humerus level• Low accessory vein apparent by physical exam

Catheter across anastomosis

Angiogram of accessory vein

Coil in place

Radiocontrast through catheter in accessory vein

Final angiogram

Coding of Case

2009• 75790 – Angiogram of access• 36011 – Selective

catheterization of first order vein

• 37204 – Placement of embolization coil

• 75894 - Radiological S & I for 37204

• 75898 – Follow-up angiogram for coil embolization

2010• 36147 – Cannulation and

access angiogram• 37204 – Placement of

embolization coil• 75894 - Radiological S & I for

37204• 75898 – Follow-up angiogram

for coil embolization