Three Steps for AV Dialysis Fistula Maintenance Coding
Published on Tue May 01, 2001
Some carriers are erroneously bundling services like angioplasty into CPT 36870 (thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft [includes mechanical thrombus extraction and intra-graft thrombolysis]) even though it should be paid separately.
AV dialysis fistula maintenance is performed with kidney patients undergoing regular dialysis treatments, according to Gerald Johnson, MHA, CHE, administrator of diagnostic and therapeutic radiology services at the Danville Regional Medical Center in Danville, Va. When dialysis is needed, a urologist and surgeon create a reservoir or fistula in the patients forearm, and insert a shunt to connect the arterial and venous systems. This shunt allows blood to be routed out of the patient through dialysis equipment and back into the patient.
Because of the slower flow of blood, clots sometimes form in the fistula, interfering with dialysis. An interventional radiologist may then perform a thrombectomy, remove the clot and re-establish the flow of blood through the shunt. In other instances, a vascular surgeon may also need to perform an open excision of the clot.
Some Carriers Wrongly Bundle
On occasion, the interventional radiologist may first attempt balloon angioplasty to reopen the lumen, Johnson says. If that effort fails, the physician will then perform the thrombectomy to declot the fistula. Both services should be documented and reported. Some coders state, however, that many carriers inappropriately deny the angioplasty as bundled into the thrombectomy.
These bundling problems are a carry-over from temporary HCPCS Code G0159, which was replaced by 36870 this year, Johnson notes. Carriers began including related services with the level II code and have continued the practice this year, despite the fact that this code was not intended to be inclusive. Organizations like the Society for Cardiovascular and Interventional Radiology (SCVIR) are working closely with Medicare policymakers to correct this, and many coders say their carriers have gradually begun paying for the component codes.
The many steps of the declot procedure may be coded and billed separately.
Step 1: Access to the AV graft. The interventionalist percutaneously punctures the fistula to begin the declotting procedure, according to Lisa Grimes, radiology special procedures technologist and reimbursement specialist for The University of Texas/Houston, Health Science Center. This is coded with nonselective code 36145 (introduction of needle or intracatheter; arteriovenous shunt created for dialysis [cannula, fistula, or graft]).
Sometimes, the radiologist will create two access points on opposites sides of the site if he or she cant effectively reach the clot from one side, she explains. Dictation will often say, Accessed in a crossing fashion.
If two access points are [...]
