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

2. Vessel Definitions

3. 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

4. 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

5. 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

6. Coding Access Angioplasty

7. 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

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

9. Multiple Angioplasties

10. 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

11. Vessels Outside the Access
Any lesion present within a distinctly separate central venous structure, warrants a separate code
Treatment of a lesion within a distinctly separate feeding artery warrants a separate code
A separate supervision and interpretation code, (for venous) or (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

12. 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

13. 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

14. Changes In Cannulation Codes

15. 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

16. Non-selective cannulation for purposes of an access angiogram
The code 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 have now been discontinued

17. 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

18. 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

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

20. 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

21. Angiogram Performed With Cannulation
Already discussed on slide 16
The 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)
All catheter insertion and manipulation within the access is bundled except as listed for selective catheterization of an artery

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

23. 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

24. 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 would be used for the procedure.

25. Separate angiogram of access code without cannulation code
How can the cannulation code in the 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 nor can be used together with 75791

26. 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 should not be coded (no reason)
A cannulation for therapeutic purposes may be done

27. SUMMARY AND CONCLUSIONS

28. 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

29. 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

30. Illustrative Cases for Coding

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

32. Angioplasty of Venous Stenosis
Uncomplicated

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

34. 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

35. Stenosis at anastomosis

36. Draining veins normal

37. Central veins normal

38. SVC normal

39. Graft, anastomosis and artery - normal

40. Angioplasty performed

41. Results of treatment

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

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

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

45. Examination Left forearm loop graft Augments poorly
Thrill at venous anastomosis

46. Stenosis at venous anastomosis

47. Cephalic normal

48. Central veins normal

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

50. Stenosis of arterial anastomosis

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

52. Post angioplasty

53. Coding of Case 2009 2010 36145 - Cannulation of graft
Angiogram of graft
nd cannulation
G0393 , Venous angioplasty
G0392 , Arterial angioplasty
Arteriogram
36147 – Cannulation and access angiogram
36148 – Second cannulation for therapeutic purposes
35475 , Arterial angioplasty
Arteriogram

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

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

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

57. Anastomosis stenosis

58. Basilic stenosis

59. Brachiocephalic vein stenosis

60. 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

61. Central veins and SVC angiogram

62. Basilic angioplasty with 8 X 4

63. Anastomosis angioplasty with 8 X 4

64. Angioplasty with 12 X 4

65. Post treatment result

66. 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

67. Arterial anastomosis

68. Coding of Case 2010 2009 36010 - Selective catheterization of SVC
Angiogram of graft
Angiogram of SVC
G0393, Venous angioplasty
G , nd venous angioplasty
35476 , rd venous angioplasty
Cannulation and access angiogram
35476 , Venous angioplasty
, nd venous angioplasty

69. Thrombectomy
Arterial embolus

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

72. Stenosis of anastomosis

75. 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

76. Arteriogram
Done via catheter inserted into brachial artery – selective catheterization

77. Arterial Embolectomy

78. Coding of Case 2009 2010 36145 - Cannulation 75790 Angiogram of graft
Thrombectomy
G0393 , Venous angioplasty
Selective catheterization of 1st order artery
Arteriogram
Embolectomy, brachial
36147 – Cannulation and access angiogram
Thrombectomy
35476, Venous angioplasty
Selective catheterization of 1st order artery
Arteriogram
Embolectomy, brachial

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

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

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

82. Initial Angiogram

83. Angioplasty #1

84. Angioplasty #2

85. Post - angioplasty

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

87. Poor Development of Fistula
Accessory vein

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

89. 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

90. Catheter across anastomosis

91. Angiogram of accessory vein

92. Coil in place

93. Radiocontrast through catheter in accessory vein

94. Final angiogram

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