Coding dialysis access
BY C. MATTHEW HAWKINS
I heard that the dialysis access code set has been redone for 2017, completely changing how these services will be reported. Can you briefly summarize this code set?
Beginning Jan. 1, 2017, reporting procedures performed in arteriovenous (AV) dialysis circuits will change substantially. Briefly, the new code set consists of six codes (36901–36906) used to report services in the peripheral dialysis segment (defined as the segment of the circuit extending from the AV anastomosis to the junction of the subclavian and cephalic veins), two new add-on codes (36907–36908) used to report interventions (angioplasty and stenting) in the central dialysis segment (defined as the subclavian vein, innominate vein and superior vena cava in the upper extremity) and one new add-on code (36909) used to report embolization of any venous component of the dialysis segment. These codes include all catheterizations, angiography, fluoroscopic guidance, road-mapping, radiological supervision and interpretation, and closure of the puncture(s) performed during the procedure. An exhaustive description of the code set is further provided in the introductory language of the CPT 2017 Professional Edition codebook.
New code 36901 is used to describe all diagnostic evaluation of a dialysis circuit, including antegrade and/or retrograde punctures, all catheter manipulations within the dialysis circuit (including advancement of the catheter into the SVC), catheterization of any and all venous side-branches, as well as catheterization of the arterial inflow to evaluate the arterio-venous anastomosis. If a limited diagnostic fistulagram is performed, either because portions of the hemodialysis circuit don’t need to be evaluated or cannot be evaluated, is this limited exam reported with 36901 or 36901-52 (reduced services modifier)?
The 36901code descriptor language includes the word “necessary,” which is key to answering this question. Also, clinical judgment must be included in decision making. For example, if there is a palpable thrill in the peripheral segment of the fistula and examination is limited to the peripheral segment and the fistulagram adequately answers the question “Is there a stenosis?,” then 36901is appropriate. If instead there was a clinical suspicion of a central venous stenosis but central imaging was not acquired (e.g., technical complications), then, depending on the documentation, 36901-52 or 36901-53would be appropriate to report since all “necessary” imaging was not obtained to answer the clinical question.
If I embolize three different dialysis circuit venous side-branches during a single therapeutic session, how many times may I report add-on code 36909 (dialysis circuit endovascular vascular embolization)?
The add-on code 36909(dialysis circuit endovascular vascular embolization) should be reported only once when three different dialysis circuit venous side-branches are embolized during a single therapeutic session.
If I embolize seven different venous side-branches during a single therapeutic session, how many times may I report add-on code 36909 (dialysis circuit endovascular vascular embolization)?
Add-on code 36909(dialysis circuit endovascular vascular embolization) maybe reported only once per therapeutic session.
Can embolization of main or side-branch vessels in a dialysis circuit be reported with code 37241 (vascular embolization or occlusion; venous, other than hemorrhage)?
No. Embolization of any portion of a dialysis circuit must be reported with add-on code 36909(dialysis circuit endovascular vascular embolization) and may be reported only once per therapeutic session.
How do you report a diagnostic catheter that advanced retrograde beyond the peri-anastamotic segment into the inflow artery to perform diagnostic angiography?
Reporting diagnostic catheterization depends on the purpose of catheterization of the parent artery. If the artery is catheterized to define or treat pathology separate and distinct from the dialysis circuit, then code 36215(selective catheter placement, arterial; each first order thoracic or brachiocephalic branch) may be used to report selective catheterization of the inflow artery if performed retrograde through the dialysis circuit. Also, in this instance, code 75710(angiography, extremity, unilateral, RS&I) may be reported to account for radiologic supervision and interpretation if diagnostic angiography is performed. If catheterization of the parent artery is performed to better image the dialysis circuit, only the dialysis circuit codes may be reported.
Is diagnostic angiography always required when reporting fistula interventions, 36902–36906?
No diagnostic study is required if it is not “necessary” when reporting 36902–36906. For instance, if a patient has had a recent diagnostic study (36901) but the therapeutic intervention was delayed another day for clinical reasons, a repeat diagnostic study is not required when the patient returns for an intervention. No reduced services modifier is required in these circumstances.
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