The Latest on Dialysis Access Maintenance Reporting
Understanding the procedures and patient scenarios will help you code this evolving specialty.
Dialysis access maintenance is one area of interventional radiology coding that always seems to be evolving. This can make it difficult to code these encounters. To be sure you are current with the latest changes, here is a refresher on how to report angioplasty, stent placement, thrombectomy, and embolization of hemodialysis arteriovenous grafts (AVG) and arteriovenous fistulae (AVF).
AVGs and AVFs are types of hemodialysis access. An AVF is a direct connection between an artery and a vein; and an AVG is an indirect connection between the artery and vein.
An AVG may consist of a plastic tube, or it may be made of cadaver arteries or veins. Often, grafts and fistulas develop occlusions (blockages) that require therapeutic intervention such as angioplasty, thrombectomy, stent placement, or embolization to restore proper flow within the graft.
When coding such services, AV dialysis shunts are considered one vessel. The AV shunt begins with the arterial anastomosis and extends to the right atrium. This definition includes both upper and lower extremity AVF/AVG (CPT® Professional Edition, 2016).
A physician most often gains access into the AVF/AVG by direct puncture; however, occassionally the physician chooses to access the AVF/AVG via the brachial artery or other point of access. After gaining access, the physician places the catheter at the desired position and injects contrast material to visualize the occlusion. This is called a fistulagram.
Dialysis Access Catheterization and Fistulagram Codes
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)
+36148 additional access for therapeutic intervention
75791 Angiography, arteriovenous shunt (eg, dialysis patient fistula/graft), complete evaluation of dialysis access, including fluoroscopy, image documentation and report (includes injection of all contrast and all necessary imaging from the arterial anastomosis and adjacent artery through the entire venous outflow including the inferior and superior vena cava), radiological supervision and interpretation
CPT® 36147 describes a direct puncture into the AVG/AVF followed by injection of contrast for evaluation of the hemodialysis access. This code not only includes imaging of the AVG/AVF, but also the venous outflow all the way to the superior and inferior vena cava.
Do not assign 75825 Venography, caval, inferior, with serialography, radiological supervision and interpretation and 75827 Venography, caval, superior, with serialography, radiological supervision and interpretation when only the hemodialysis access is evaluated.
Following imaging, the physician may elect to perform a therapeutic intervention through the existing access, used to perform the fistulagram, or a new access. Assign 36147 one time per encounter, regardless of the number of fistulagrams performed with or without performance of a therapeutic intervention.
If the therapeutic intervention is performed through a second direct puncture into the hemodialysis access, assign +36148 in addition to 36147. Report +36148 only when a therapeutic intervention is performed via the second access. If the second access is used only for additional imaging do not report +36148. You may report +36148 more than once if an additional access is required for a therapeutic intervention, but these cases are rare.
Report 75791 when the physician performs a fistulagram through a different means of access (other than direct puncture of the hemodialysis access), such as via an existing access or by an initial access in a lower extremity or upper extremity artery. Like 36147, 75791 includes imaging of the AVG/AVF and also the venous outflow all the way to the superior and inferior vena cava. In addition to 75791, report any applicable catheterization code(s).
General Rules for Therapeutic Interventions
Although AV dialysis shunts are considered one vessel for coding purposes, with the AV shunt beginning with the arterial anastomosis and extending to the right atrium for fistulagrams, when coding therapeutic interventions in AV shunts, this area is divided into two vessel segments. The two designated treatment zones are:
1. AVG/AVF: includes the area from the peri-arterial anastomosis all the way through the axillary vein or the entire cephalic vein in the case of a cephalic venous outflow.
2. Central segment: consists of the subclavian, innominate, and the vena cava. These three vessels make up their own vessel or “zone” when coding.
When procedures are performed outside of the graft in the separate, central segment, you may assign additional codes for the intervention performed in the central segment. Regardless of the number of lesions treated in each zone, you may report each therapeutic intervention only one time, per zone.
Percutaneous transluminal angioplasty (PTA) eliminates areas of narrowing or occlusion in AV dialysis shunts. During a PTA, a balloon catheter is inserted through the skin into a vessel to the site of narrowing, and the balloon is inflated to restore flow to the vessel.
Dialysis Access Angioplasty Codes
35475 Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel
75962 Transluminal balloon angioplasty, peripheral artery other than renal, or other visceral artery, iliac or lower extremity, radiological supervision and interpretation
35476 Transluminal balloon angioplasty, percutaneous; venous
75978 Transluminal balloon angioplasty, venous (eg, subclavian stenosis), radiological supervision and interpretation
Angioplasty is reported only one time, regardless of the number of lesions treated in a vessel. The Society of Interventional Radiology (SIR) has stated that all angioplasty performed within the hemodialysis access vessel is coded as a single angioplasty, regardless of the number of stenoses treated within the segment (from the level of the inflow artery, through the length of the graft to the venous outflow to the level of the axillary vein). This same logic applies to stent placement.
The AV dialysis shunt is considered to be a venous vessel and, therefore, most of these interventions are coded with the venous intervention codes. Report 35476 and 75978 once to describe all angioplasty within the AV dialysis shunt, regardless of the number of lesions treated within the segment or the number of balloon inflations. There are some exceptions to this rule:
Angioplasty is performed of the arterial anastomosis only: Report 35475 and 75962 instead of 35476 and 75978 because this is considered an arterial angioplasty.
Angioplasty is performed in both the arterial anastomosis and the venous anastomosis or within the graft: Assign 35475 and 75962 over the venous angioplasty codes, in accordance with National Correct Coding Initiative (NCCI) edits.
When the AVG/AVF is present in the lower extremities, assign 37224 or 37220 for angioplasty at the arterial anastomosis, depending on the exact location, instead of 35475 and 75962, which are assigned for upper extremity angioplasty.
You may assign codes when angioplasty is performed in the central veins (subclavian/innominate/vena cava) or within a native artery. In addition to the codes used to describe the angioplasty of the graft, report either 35476/75978 or 35475/75962, depending on the location of the angioplasty. If one or more central venous stenoses are treated with angioplasty, report a single venous angioplasty, regardless of the number of lesions treated within the segment because the central veins are considered their own treatment “zone.”
Dialysis Access Stent Codes
37236 Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery
+37237 each additional artery
37238 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; initial vein
+37239 each additional vein
Report stent placement only one time, regardless of the number of stents placed within the hemodialysis access vessel; the AV shunt is considered to be a venous vessel when selecting the stent placement code. Code 37238 describes a venous stent placement, and is reported once to describe all stents placed in the hemodialysis access segment, regardless of number of lesions treated within the segment. There are some exceptions to this rule:
A stent is placed at the arterial anastomosis only: Report 37236 instead of 37238 because this is considered an arterial stent placement.
A stent is placed at both the arterial anastomosis and the venous anastomosis or within the graft: Report 37236 over the venous stent code.
When the AVG/AVF is present in the lower extremities: Report 37226 or 37221 for stent placement at the arterial anastomosis depending upon the exact location, instead of 37236.
You may report stent placement in the central veins (subclavian/innominate/vena cava) in addition to stent placement in the graft. The correct code for stent placement in the central zone will depend on the code reported for the stent placed in the hemodialysis access vessel. If you assign 37236 for the graft stent placement, you should assign 37238 for the central segment stent (not 37239) because CPT® instructs to use 37239 with 37238 (not 37236). If you assign 37238 for the graft stent placement, assign +37239 for the central segment stenting.
Note that angioplasty is bundled with stent placement codes 37236-37239 when performed in the same vessel; therefore, the stent codes take precedence over the angioplasty codes. For example, when an angioplasty is performed at the arterial anastomosis and a stent is placed with the hemodialysis access vessel, assign 37238, with the arterial angioplasty bundled.
Dialysis Access Thrombectomy Codes
36870 Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical thrombus extraction and intra-graft thrombolysis)
Thrombectomy is performed to remove a thrombus from an occluded AV dialysis shunt using a device such as an AngioJet®, Trerotola®, Amplatz®, or Fogarty® catheter, and is described by 36870.
Code 36870 includes all of the work necessary to remove the thrombus, both mechanical and pharmacological; therefore, thrombolysis of the shunt is also included in this code. The codes for thrombolysis (37211-37214) may only be assigned when thrombolysis is performed through a catheter in a separate and distinct vessel from the shunt. If a balloon is used to facilitate a thrombectomy, it is considered part of the thrombectomy and should not be coded separately. Angioplasty should only be reported additionally when an underlying stenosis is treated in addition to a thrombotic occlusion. A balloon catheter used for removal of an arterial plug should not be assigned a separate code.
Dialysis Access Embolization Codes
37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)
36011 Selective catheter placement, venous system; first order branch (eg, renal vein, jugular vein)
36012 second order, or more selective, branch (eg, left adrenal vein, petrosal sinus)
Although less common, a physician may need to perform embolization of a hemodialysis access. Assign 37241 to report venous embolization of hemodialysis access. Because the hemodialysis access and its branches are considered one operative field, assign 37241 only one time, regardless of the number of embolized branches.
When the embolization procedure requires catheterization of collateral veins (additional venous side branches), assign the selective venous catheterization codes 36011 and 36012, as appropriate. You may report codes in addition to 36147 and +36148 (SIR Interventional Radiology Coding Update 2015).
Access is gained via direct puncture into the AVG. A fistulagram is performed. A second puncture is made at the opposite end of the AVG for therapeutic intervention. Angioplasty is performed at the venous anastomosis and the arterial anastomosis.
Codes: 36147, +36148, 35475, 75962
Access is gained via direct puncture into the AVG. A fistulagram is performed. An angioplasty is performed of the AVG, followed by angioplasty of the subclavian vein.
Codes: 36147, 35476, 75978, 35476-59, 75978-59
Access is gained via direct puncture into the AVG. A fistulagram is performed. A second puncture is made at the opposite end of the AVG for therapeutic intervention. An angioplasty is performed at the venous anastomosis, followed by stent placement in the AVG.
Codes: 36147, +36148, 37238
Access is gained via direct puncture into the AVG. A fistulagram is performed. A second puncture is made at the opposite end of the AVG for therapeutic intervention. Angioplasty is performed within the AVG followed by stent placement at the arterial anastomosis.
Codes: 36147, +36148, 37236
Access is gained via direct puncture into the AVG. A fistulagram is performed. Angioplasty is performed at the arterial anastomosis followed by stent placement within the AVG.
Codes: 36147, 37238
Access is gained via direct puncture into the AVG. A fistulagram is performed. Angioplasty and stent placement are performed in the AVG. A collateral vein is catheterized and embolized.
Codes: 36147, 36011, 37241, 37238
Access is gained via direct puncture into the AVG. A fistulagram is performed. A second puncture is made at the opposite end of the AVG for therapeutic intervention. A thrombectomy is performed and a balloon catheter is used to clear the arterial plug.
Codes: 36147, +36148, 36870
Stacie L. Buck, RHIA, CIRCC, CCS-P, RCC, is president and senior consultant at RadRx in Stuart, Fla. (www.radrx.com). She is a national speaker who provides consulting services to providers of diagnostic and interventional radiology services and is the author of the book Cracking the IR Code: Your Comprehensive Guide to Mastering Interventional Radiology Coding and creator of Mastering Interventional Radiology & Cardiology Virtual Boot Camps. Buck may be contacted at firstname.lastname@example.org. She is a member of the Stuart, Fla., local chapter.