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

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 - 35475

8. 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

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 - 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

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 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

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 & 36126 (36245 in lower extremity) • Selective catheterization of venous side branches is considered to be bundled with 36147 • 36011 & 36012 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 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

22. 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

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 75791 would be used for the procedure.

25. 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

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 36147 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 35476 – Venous angioplasty 75978 – S&I for 35476 • 36145 - Cannulation • 75790 - Angiogram of access • G0393 -Venous angioplasty • 75978 - S & I for G0393

43. Angioplasty Venous and arterial problem

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