coding of procedures in interventional nephrology: overview of changes in the 2010 revision
TRANSCRIPT
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