Coding of Procedures in Interventional Nephrology: Overview of changes in the 2010 revision

Vessel Definitions

Central versus Peripheral The anatomy texts do not contain a definition of central and peripheral veins Central veins Upper - Veins within the boney thorax Lower – Veins within the boney pelvis Peripheral veins Veins of extremity up to central veins

Definition of Access The vascular access is considered to be a separate vessel by definition It extends from the arterial anastomosis through to the beginning of the central veins, i.e., the subclavian The arterial anastomosis with the adjacent 2 cm of artery is defined as the arterial portion of the access The entire remainder of the access is defined as the venous portion for coding purposes

Coding Changes for 2010 New codes 36147 – Cannulation and access angiogram 36148 – Second cannulation for therapeutic purposes 75791 – Angiogram of access without cannulation Code deletions G0392 – Arterial angioplasty within access G0393– Venous angioplasty within access 36145 – Non-selective cannulation 75790 – Angiogram of access

Coding Access Angioplasty

New Policy Guidelines In 2006 CMS issued two new G codes take effect on January 1, 2007 Venous angioplasty – G0393 Arterial angioplasty – G0392 These have been discontinued, we are to back to using the old standard codes Venous angioplasty – 35476 Arterial angioplasty - 35475

Potential Confusion There are special regulations that relate to angioplasty within the access However 35475 and 35476 must be used for all angioplasty both outside of and within the access Good documentation is important

Multiple Angioplasties

Within the Access Situations in which multiple angioplasties may be coded are very limited Although multiple lesions may be present within the access one is permitted to use only a single code If these multiple treatments within the access are all venous, then a single venous angioplasty code, 35476, should be used If both an arterial angioplasty (arterial anastomosis) and a venous angioplasty are performed within the access, only the arterial treatment should be coded using 35475

Vessels Outside the Access Any lesion present within a distinctly separate central venous structure, warrants a separate code - 35476 Treatment of a lesion within a distinctly separate feeding artery warrants a separate code - 35475 A separate supervision and interpretation code, 75978 (for venous) or 75962 (for arterial), should be paired with each of the angioplasty codes The second venous (within the central veins) or arterial angioplasty (within the feeding arteries) should have a -59 modifier attached as should the second venous S&I code The second arterial angioplasty has a different S&I code, 75964

Coding Multiple Angioplasties No more than two angioplasty codes should be used in any case This could be one arterial (for the anastomosis or a feeding artery) and one venous (for a central venous lesion) two venous - one in the access and one central two central and none in the access Two arterial (the anastomosis and a feeding artery, or two feeding artery) Any time two angioplasty codes are used very good documentation should be supplied to explanation the rational for the two codes

Contiguous Lesions If a single lesion extends across two adjacent separate vessels, treatment warrants only a single angioplasty code In instances in which the exact anatomical identity of the vessel is critical for coding purposes, a lesion that bridges across two vessels should be defined by the vessel in which it lies predominantly Two codes are warranted only in instances in which separate distinct lesions are present in separate vessels, provided that the two vessels qualify for separate coding based upon the access versus central veins rule as described

Changes In Cannulation Codes

Basics Cannulation or catheterization may be either selective or non-selective Selective cannulation is a column 1 code and non-selective is a column 2 and these two codes are mutually exclusive The most frequently performed cannulation is non-selective The target vessel is entered directly and no further manipulation is required This cannulation can be performed under two circumstances – Non-selective cannulation to perform an angiogram of the access Non-selective cannulation for a therapeutic intervention With the new regulations, these two procedure types should be coded differently

Non-selective cannulation for purposes of an access angiogram The code 36147 is a new code for 2010 This code bundles an angiogram of the access with a non-selective cannulation performed for the purpose of performing the study This code is specific for the dialysis access (either fistula or graft) Not an appropriate code for use when a vein is cannulated as for vein mapping 36145 and 75790 have now been discontinued

Non-selective cannulation for therapeutic purposes If a non-selective cannulation of the access is performed for the purpose of performing a therapeutic intervention, another new code, 36148, should be used This would be used for the second cannulation done for a thrombectomy, for example

Selective catheterization (cannulation) A selective catheterization code cannot be used with a nonselective code for the same site The selective code should be treated as a column 1 code and the nonselective as a column 2 code and the two are mutually exclusive Two situations: Only one non-selective cannulation – list only the angiogram (discussed further below) A second nonselective cannulation is performed - this should be dropped in favor of selective code The basic principle is - each time a site is used for a selective catheterization, a non-selective code is dropped in favor of the selective one

Restrictions On Selective Catheterization Only selective catheterization of a first or second order artery is allowed 36215 & 36126 (36245 in lower extremity) Selective catheterization of venous side branches is considered to be bundled with 36147 36011 & 36012 can not be used

Angiogram of Access An angiogram of the access can actually be coded three different ways depending upon the individual situation: Angiogram performed with cannulation Angiogram only Angiogram performed through a pre-existing cannulation of access Separate angiogram of access code without a cannulation code Separate coding of angiogram components

Angiogram Performed With Cannulation Already discussed on slide 16 The code 36147 bundles an angiogram of the access with a non-selective cannulation performed for the purpose of performing the study This code is specific for the dialysis access (either fistula or graft) All catheter insertion and manipulation within the access is bundled except as listed for selective catheterization of an artery

Codes Bundled With 36147 36145 – Cannulation of access 75790 - Angiogram of access 76000 - Fluoroscopy (separate procedure) up to one hour physician time 75820 - Venography, extremity, unilateral 75825 - Venography, caval, inferior, with serialography 75827 - Venography, caval, superior, with serialography 36140 – Cannulation of extremity artery (excludes brachial) 36010 – Selective catheterization of superior or inferior vena cava

Angiogram Only 75791 should be used for an access angiogram when a cannulation is not performed This code should not be used except where the angiogram is being coded without an accompanying non-selective cannulation Angiogram performed through a pre-existing cannulation of access Separate angiogram of access code without a cannulation code

Angiogram performed through a pre-existing cannulation of access Occasionally the patient presents to the angiography suite with a needle or catheter already in place. In this instance, the access does not require cannulation in order to perform the angiogram. In this instance the code 75791 would be used for the procedure.

Separate angiogram of access code without cannulation code How can the cannulation code in the 36147 bundle be dropped while maintaining the angiogram coding This should be done by listing the angiogram as a separate study using the code 75791 If a second cannulation for therapeutic purpose, code 36148, has been the site of the selective catheterization, it would simply be dropped in favor of the selective code Remember that neither 36147 nor 36148 can be used together with 75791

Separate coding of angiogram components In order to qualify as a separate procedure and be coded separately, the angiogram must be performed by cannulating a separate site, a site that is not part of the access as defined 75820 or 75827, should be listed with a -59 modifier In this setting 36147 should not be coded (no reason) A cannulation for therapeutic purposes may be done

SUMMARY AND CONCLUSIONS

New regulations have been scheduled to begin January 1, 2010 Important that the interventionalist dealing with dialysis access procedures become familiar with these and become accustomed to their application As is always the case there is very likely to be confusion initially before the changes become infused throughout the system

A complete copy of the new manual may be obtained from the “Members Only” websites of either ASDIN or RPA Use of uniform coding practices and consistently following a set of standardized recommendations such as those represented in the Coding Manual is very important It is only by doing this that our Society will be able to speak in the future with a strong, unified voice in matters that relate to this very important aspect of our rapidly growing field

Illustrative Cases for Coding

Tunneled Catheter Placement There are no changes in coding in this category of procedures

Angioplasty of Venous Stenosis Uncomplicated

History 64 year old male Polycystic kidney disease Dialysis for 5 years Loop graft in left arm Referred for low flow

Physical Examination Loop graft in left forearm Hyper-pulsatile Augmented well Prominent thrill at venous anastomosis High pitched bruit at venous anastomosis, diastolic component diminished

Stenosis at anastomosis

Draining veins normal

Central veins normal

SVC normal

Graft, anastomosis and artery - normal

Angioplasty performed

Results of treatment

Coding of Case 2009 2010 36147 - Cannulation with angiogram 75790 - Angiogram of access G0393 - Venous angioplasty 75978 - S & I for G0393 36147 - Cannulation with angiogram 35476 – Venous angioplasty 75978 – S&I for 35476

Venous and arterial problem Angioplasty Venous and arterial problem Case with Venous angioplasty 2 arterial angioplasties Selective catheterization – 2nd order

History 48 year old male On hemodialysis for 3 years Left forearm loop graft Has 10% recirculation Poor flow

Examination Left forearm loop graft Augments poorly Thrill at venous anastomosis

Stenosis at venous anastomosis

Cephalic normal

Central veins normal

Angioplasty done with 8 X 4 balloon Lesion dilated completely with no residual

Stenosis of arterial anastomosis

Next Step Graft cannulated second time on arterial side Arterial anastomosis dilated with 6 X 4 balloon

Post angioplasty

Coding of Case 2009 2010 36145 - Cannulation of graft 75790 - Angiogram of graft 36145-59 - 2nd cannulation G0393 , 75978 - Venous angioplasty G0392 , 75962 - Arterial angioplasty 74710 - Arteriogram 36147 – Cannulation and access angiogram 36148 – Second cannulation for therapeutic purposes 35475 , 75962 - Arterial angioplasty 74710 - Arteriogram

Venous angioplasties and SVC angiogram Graft With Poor Flow Venous angioplasties and SVC angiogram 3 venous angioplasties Superior vena cava angiogram

History 50 year old male with forearm loop graft Referred for decreased flow Has had previous central venous catheters

Physical Examination Graft was hyper-pulsatile Collateral veins on upper arm and chest

Anastomosis stenosis

Basilic stenosis

Brachiocephalic vein stenosis

Next Step After multiple attempts, a guidewire was passed across the innominate lesion A catheter was passed across the lesion Superior vena cava angiogram and angiogram of central veins was performed through catheter

Central veins and SVC angiogram

Basilic angioplasty with 8 X 4

Anastomosis angioplasty with 8 X 4

Angioplasty with 12 X 4

Post treatment result

Inflow Evaluation The flow in the graft as tested with a bolus of radiocontrast appeared to be excellent The graft augmented well Conclusion good inflow

Arterial anastomosis

Coding of Case 2010 2009 36010 - Selective catheterization of SVC 75790 - Angiogram of graft 75827-59 - Angiogram of SVC G0393, 75978 - Venous angioplasty G0393 -59, 75978-59 - 2nd venous angioplasty 35476 , 75978 - 3rd venous angioplasty 36147 - Cannulation and access angiogram 35476 , 75978 - Venous angioplasty 35476 -59, 75978-59 - 2nd venous angioplasty

Thrombectomy Arterial embolus

History The patient is a 47 year old male Left upper arm straight graft Referred for thrombectomy

Stenosis of anastomosis

Thrombectomy done in standard manner No difficulties encountered initially With use of Fogarty patient began to appear uncomfortable Examination revealed that hand was cold and the radial pulse that had been present earlier was now gone

Arteriogram Done via catheter inserted into brachial artery – selective catheterization

Arterial Embolectomy

Coding of Case 2009 2010 36145 - Cannulation 75790 Angiogram of graft 36870 - Thrombectomy G0393 , 75978 - Venous angioplasty 36215 - Selective catheterization of 1st order artery 75710 - Arteriogram 37186-59 - Embolectomy, brachial 36147 – Cannulation and access angiogram 36870 - Thrombectomy 35476, 75978 - Venous angioplasty 36215 - Selective catheterization of 1st order artery 75710 - Arteriogram 37186-59 - Embolectomy, brachial

Juxta-Anastomotic Stenosis Poor Flow in Fistula Juxta-Anastomotic Stenosis

History 48 year old male Radial-cephalic fistula Fistula is 2 years old History of difficult cannulation Poor flow

Physical Examination Radial-cephalic fistula in right arm Poorly palpable in upper portion Did not augment very well Apparent juxta-anastomotic stenosis

Initial Angiogram

Angioplasty #1

Angioplasty #2

Post - angioplasty

Coding of Case 2009 2010 75790 - Angiogram of fistula G0392 , 75962 - Arterial angioplasty G0393 , 75978 - Venous angioplasty 36215 – selective catheterization of 1st order artery 75710 - Arteriogram of extremity Angiogram of access without cannulation - 75791 35475, 75962 – Arterial angioplasty 36215 – selective catheterization of 1st order artery 75710 - Arteriogram of extremity

Poor Development of Fistula Accessory vein

History 32 year old male Fistula created 6 months earlier Fistula used for two months Very difficult to cannulate

Physical Examination Radial-cephalic fistula High anastomosis Strong thrill at anastomosis Fistula not palpable above mid humerus level Low accessory vein apparent by physical exam

Catheter across anastomosis

Angiogram of accessory vein

Coil in place

Radiocontrast through catheter in accessory vein

Final angiogram

Coding of Case 2009 2010 75790 – Angiogram of access 36011 – Selective catheterization of first order vein 37204 – Placement of embolization coil 75894 - Radiological S & I for 37204 75898 – Follow-up angiogram for coil embolization 36147 – Cannulation and access angiogram 37204 – Placement of embolization coil 75894 - Radiological S & I for 37204 75898 – Follow-up angiogram for coil embolization