General Surgery Coding Alert

Distinguish +36148, 75791.

If your surgeon performs an arteriovenous (AV) shunt introduction for diagnostic studies, you can't afford to miss the CPT® guidelines about what's included and what you can separately report.

Begin here: The guidelines, new in CPT® 2012, help clarify reporting for 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]).

Your surgeon might use 36147 when a patient with end-stage renal disease (ESRD) is having trouble with his AV shunt for dialysis and requires an evaluation.

Grasp the Procedure

"For diagnostic studies, the arteriovenous (AV) dialysis shunt (AV shunt) is defined as beginning with the arterial anastomosis [opening between two normally separate structures] and extending to the right atrium. This definition includes all upper and lower extremity AV shunts (arteriovenous fistulae [AVF] and arteriovenous grafts [AVG])," CPT® guidelines state.

The surgeon creates an AVF for dialysis by cutting an opening in an artery and an opening in a nearby vein and then joining the openings together so that blood can communicate between the artery and the vein. The vessels involved typically include the radial artery and the cephalic vein. An AVG also involves creating openings in an artery and a vein, but uses an artificial vessel to link the two openings.

Shun These Included Services

The guidelines point out that 36147 includes certain access and manipulation services, explained Sean P. Roddy, MD, of the CPT® Advisory Committee and Society for Vascular Surgery, in his CPT® and RBRVS 2012 Annual Symposium presentation. You should not report a separate code for the following services:

Access/imaging: The work of directly accessing and imaging the entire AV shunt is included in 36147. Per the guidelines, the puncture may be antegrade or retrograde, and the physician may inject the contrast through a needle or catheter.

Cath manipulation: Catheter advancement in the shunt and/or vena cava is included. The guidelines specify that 36147 includes all manipulation for diagnostic imaging of the shunt.

Here's what that means for you:

• You should not code separately for either advancing the catheter to the vena cava or advancing the catheter through the arterial anastomosis when done to visualize the shunt or the anastomosis, which is the surgical connection between the two vessels
• Similarly, the guidelines specify that 36147 includes evaluating the part of the inflow vessel near the surgical opening. The guidelines refer to this as the peri-anastomotic portion of the inflow. Peri- means near or around, so peri-anastomotic means the portion near or around the surgical connection between the two vessels.

Pick Up These 2 Separately Reportable Services

There are services CPT® says you may report in addition to 36147, Roddy said. These relate to ultrasound guidance and arterial inflow selective catheterization.

Ultrasound guidance: Assuming the documentation is sufficient, CPT® states that you may report ultrasound guidance for puncture of the AV shunt using +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]).

Keep in mind that reporting ultrasound with 36147 should not be standard procedure. The physician should describe the medical necessity for its use in the patient's case. Additionally, CPT® guidelines for ultrasound guidance "require permanently recorded images of the site to be localized, as well as a documented description of the localization process, either separately or within the report of the procedure for which the guidance is utilized."

Arterial inflow cath: You may report selective catheterization of the arterial inflow from the AV shunt puncture separately. That's because CPT® considers the arterial inflow to be a separate vessel from the shunt.

Guideline: Separate coding is appropriate when the physician suspects a problem separate from the peri-anastomotic segment, and that's why he advances the catheter into the artery and performs imaging. In other words, advancing the catheter into the artery just to get a better look at the anastomosis or shunt is included in 36147.

For the catheterization, you'll report a code such as 36215 (Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family). In this context, the code includes cath placement into the aorta. You should not additionally report 36200 (Introduction of catheter, aorta) for this service, Roddy said. As the guidelines explain, 36200 work is included in 36215.

Contrast with +36148, 75791

CPT® Assistant (March 2010) reminds you that you have two additional codes to consider for AV shunt services. Report +36148 (...additional access for therapeutic intervention [List separately in addition to code for primary procedure]) in addition to 36147 if the initial evaluation (36147) prompts a therapeutic intervention requiring a second shunt catheterization.

Remember that +36148 is not used to identify a second diagnostic injection procedure from a second access point. Use +36148 when an interventional procedure is provided from that second access point.

If percutaneous access had already been established prior to the service, 36147 would not be appropriate. You should instead report 75791 (Angiography, arteriovenous shunt [e.g., dialysis patient fistula/graft], complete evaluation of dialysis access, including fluoroscopy, image documentation and report [includes injections of contrast and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava), radiological supervision and interpretation]).