General Surgery Coding Alert

Check out code-level notes, too.

Despite similarities to previous dialysis circuit guidelines, you need to engage some changes to the 2017 guidelines, as well as some new text notes, to make sure you know how to use the new codes discussed in the preceding article.

With so many instructions, a refresher on all the rules, even ones that aren’t new, is a good idea. Read on to get updated definitions of the dialysis circuit and its segments, as well as helpful information about lower extremity versus upper extremity circuits.

Grasp ‘Circuit’ Parts and Definitions

The “dialysis circuit” is the connected course of arteries and veins used for repeated access for blood cleansing through hemodialysis. Your surgeon may establish access through an Arteriovenous Fistula (AVF) or Arteriovenous Graft (AVG) in the upper or lower extremities.

The full circuit is broken into two “segments” for coding purposes, as follows:

Peripheral dialysis segment: This begins at the AVF or AVG and extends to the central dialysis segment.

• For an upper extremity circuit, the peripheral segment extends through the axillary vein or the cephalic vein if the patient has cephalic vein outflow.
• For a lower extremity circuit, CPT^® defines the peripheral segment as extending through the femoral vein.

Central dialysis segment: “The central dialysis segment includes all the veins that drain toward the heart from the axillary/cephalic vein or the femoral vein, depending on the type of circuit,” explains Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash.

• For an upper extremity circuit, that includes the subclavian and innominate (brachiocephalic) veins through the superior vena cava.
• In a lower extremity circuit, that includes the external iliac and common iliac veins through the inferior vena cava.

Peripheral hint: CPT^® includes the area around the anastomosis, including a short part of the parent artery and a short part of the circuit near the anastomosis, in the peripheral segment. CPT^® 2017 terms this area the “historic peri-anastomotic region.”

Know What Services the Procedures Include

The new codes dialysis circuit codes 36901-36901 include a lot of bundled services. Here are some highlights to watch for as you read (and reread) the updated guidelines:

Includes: The new codes include the following services, if performed:

• diagnostic angiography
• direct puncture(s)
• catheter placement(s)
• contrast or pharmacological injection(s)
• imaging of the circuit
• fluoroscopic guidance
• radiological supervision and interpretation (RS&I)
• report.

Ultrasound: You may report +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]) with these dialysis circuit codes, but it should be rare. You may see ultrasound required most often for new or failing AVFs.

RS&I: In cases where a physician performs radiological supervision and interpretation of angiography through an existing access or catheter-based arterial access, you should append modifier 52 (Reduced services) to 36901.

Final tip: When dealing with major changes like this, reviewing the updated codes, researching guidelines, taking notes, and even practicing using the new codes on current cases (not to submit, of course) to get familiar with the changes can be helpful, advises Christina Neighbors, MA, CPC, CCC, coding quality auditor for Conifer Health Solutions.