Surgeons who perform dialysis access and management procedures and the medical billing and coding companies that serve them have to deal with several new CPT codes for dialysis circuit interventions in 2017. According to the CPT manual, the term ‘dialysis circuit’ refers to both arteriovenous fistula and arteriovenous grafts. Dialysis circuits can be placed at different areas in the forearm, elbow, and upper arm.
The arteriovenous (AV) dialysis circuit is the most commonly used one and provides easy and repetitive access to perform hemodialysis (HD), improving the efficiency of the procedure. Beginning at the arterial anastomosis, the AV dialysis circuit extends to the right atrium. It may be created in two ways: using either an arterial-venous anastomosis (arteriovenous fistula) or using a prosthetic graft (arteriovenous graft) placed between an artery and vein. The dialysis circuit consists of two segments: (1) the peripheral dialysis segment, and (2) the central dialysis segment.
As codes linked to dialysis circuit interventions were frequently reported together in various combinations, bundled codes have been created for reporting for the dialysis circuit in 2017. It is expected that the new codes will reduce coding complexity and ensure that all procedures are consistently by all surgical specialties.
There are nine new bundled codes to report angioplasty, stent placement, thrombectomy, embolization, and radiological supervision and interpretation within the dialysis circuit:
- 36901, Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow, including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report.
CPT guidelines state that 36901 should not be reported in conjunction with 36833 (Revision, open, arteriovenous fistula; with thrombectomy, autogenous or nonautogenous dialysis graft [separate procedure]) or 36902-36906 (Introduction of needle(s) and/or catheter(s), dialysis circuit,…).
- 36902,…with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty.
36902 should not be reported in conjunction with 36903, and more than once per operative session.
- 36903,…with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis segment
36903 is not to be reported in conjunction with 36833 (Revision, open, arteriovenous fistula; with thrombectomy, autogenous or nonautogenous dialysis graft [separate procedure]) or 36904-36906 (Introduction of needle(s) and/or catheter(s), dialysis circuit,..).
- 36904, Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s)
As per CPT® guidelines, 36904 should not be reported in conjunction with 36905 or 36906 for a similar procedure with balloon angioplasty and stent placement in a peripheral dialysis segment respectively.
- 36905, Percutaneous transluminal mechanical thrombectomy….with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty
Note: 36905 should not be reported in conjunction with 36904.
- 36906, Percutaneous transluminal mechanical thrombectomy…with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis circuit
36906 should not be reported in conjunction with 36901-36903.
- +36907, Transluminal balloon angioplasty, central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and interpretation required to perform the angioplasty (List separately in addition to code for primary procedure)
CPT® guidelines state that 36907 should be:
– Reported once for all angioplasty performed within the central dialysis segment
– Reported in conjunction with arteriovenous procedures 36818-36833, diagnostic angiography of dialysis circuit procedures (36901-36903), and percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit procedures (36904-36906).
Code 36907 is not to be reported in conjunction with 36908.
- +36908, Transcatheter placement of intravascular stent(s), central dialysis segment, performed through dialysis circuit, including all imaging radiological supervision and interpretation required to perform the stenting, and all angioplasty in the central dialysis segment (List separately in addition to code for primary procedure)
Report 36908:
– Only once for all stenting performed within the central dialysis segment
– In conjunction with arteriovenous procedures 36818-36833, diagnostic angiography of dialysis circuit procedures (36901-36903), and percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit procedures (36904-36906).
- +36909, Dialysis circuit permanent vascular embolization or occlusion (including main circuit or any accessory veins), endovascular, including all imaging and radiological supervision and interpretation necessary to complete the intervention (List separately in addition to code for primary procedure)
Code 36909 includes all permanent vascular occlusions within the dialysis circuit and may only be reported once per encounter per day. This code should be reported in conjunction with diagnostic angiography of dialysis circuit procedures (36901-36903), and percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit procedures (36904-36906).
To report open ligation/occlusion in dialysis access, use 37607 (Ligation or banding of angioaccess arteriovenous fistula).
Points to Note:
- 36901 to 36906 cannot be reported more than once per operative session.
- 36902 to 36909 include all catheterizations required to perform additional services and are not separately
- All angiography, fluoroscopic image guidance, road mapping, and radiological supervision and interpretation required to perform each procedure are included in each code
- As it is not typically performed, ultrasound guidance for puncture of the dialysis circuit access is not included in 36901 to 36906; however, if ultrasound may be found necessary, it may be reported with 76937 (ultrasound guidance for vascular diagnostic and interventional procedures), provided all appropriate elements are performed and documented.
Reporting these codes correctly for optimal reimbursement would be much easier with help from an experienced medical billing company. Reliable service providers have professional teams of certified coders and billing experts who keep track of these changes and can ensure the correct use of new and revised medical codes.
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