Author: Kimberly Mansingh

We are continuing our series on notable changes for CPT in 2019. Another area of the code manual that received a pretty extensive overhaul involved the codes for FNA biopsies. The acronym FNA stands for “fine needle aspiration.” In this technique, the surgeon typically aspirates fluid for biopsy using a fine gauge needle (he/she will often use a 22 or 25 gauge needle in this procedure). The surgeon then withdraws fluid (e.g., from a cyst) or may withdraw clusters of cells from a solid mass and that specimen is sent to pathology to obtain a diagnosis. The term “biopsy” was added to the FNA codes in 2019 to clarify that these codes should not be reported if the intent of the procedure is simply to drain fluid (there are other codes for fluid drainage in CPT). The intent of these FNA biopsy codes is to report use of a fine gauge needle to withdraw a specimen for purposes of biopsy (i.e., getting a diagnosis from the specimen).

In 2018, we only had two codes available for an FNA biopsy: CPT 10021 for an FNA biopsy without imaging guidance and 10022 for an FNA biopsy with imaging guidance. For CPT 10022 for the FNA biopsy with imaging guidance, you then had to add a second code to represent the exact type of imaging guidance used (77002 for fluoroscopy, 76942 for ultrasound, 77012 for CT guidance, or 77022 for MR guidance).

For 2019, though, we now have combination codes that capture FNA biopsy performed using specific types of imaging guidance (e.g., FNA biopsy with fluoroscopic guidance is all captured with a single code). The codes have also been designed to include primary codes for FNA biopsy of the first lesion and add on codes for each additional lesion where FNA biopsy is performed using the same type of imaging guidance.

Let’s start by looking at all of the new codes and their descriptions:

FNA Biopsy Without Imaging Guidance

10021  -Fine needle aspiration biopsy, without imaging guidance; first lesion

+10004 –Fine needle aspiration biopsy, without imaging guidance; each additional lesion (list separately in addition to code for primary procedure)

FNA Biopsy With Ultrasound Guidance

10005 –Fine needle aspiration biopsy, including ultrasound guidance; first lesion

+10006 –Fine needle aspiration biopsy, including ultrasound guidance;each additional lesion (list separately in addition to code for primary procedure)

FNA Biopsy with Fluoroscopic Guidance

10007 –Fine needle aspiration biopsy, including fluoroscopic guidance; first lesion

+10008 –Fine needle aspiration biopsy, including fluoroscopic guidance; each additional lesion (list separately in addition to code for primary procedure)

FNA Biopsy with CT Guidance

10009 –Fine needle aspiration biopsy, including CT guidance;first lesion

+10010 –Fine needle aspiration biopsy, including CT guidance;each additional lesion (list separately in addition to code for primary procedure)

FNA Biopsy with MR Guidance

10011 –Fine needle aspiration biopsy, including MR guidance;each additional lesion (list separately in addition to code for primary procedure)

+10012 –Fine needle aspiration biopsy, including MR guidance;each additional lesion (list separately in addition to code for primary procedure)

With the creation of these new codes for FNA biopsy, there are a couple of key guidelines to keep in mind:

• You can no longer report imaging guidance codes 77002, 76942, 77012, or 77022 with the FNA biopsy codes to report the imaging guidance used to perform the FNA biopsy itself or a core biopsy on the same lesion during the same encounter. Again the new combination codes already include the work of the FNA biopsy plus the specific form of imaging guidance in a single code. Coding tip: It would be permissible to report one of these imaging codes with an FNA biopsy code if the imaging was used to complete a procedure other than the FNA biopsy or a core needle biopsy on the same lesion during the same encounter.

• If “multiple passes” (i.e., multiple FNA biopsies) are obtained of the same lesion, you will still report only one unit of the FNA biopsy code that describes how that FNA biopsy was obtained. For example, if a surgeon performs an FNA biopsy under CT guidance for a nodule in the left thigh and he makes four passes into that nodule during the procedure to ensure he obtains adequate tissue for pathology, you will code CPT 10009 with only 1 unit. Even though four “passes” were made, he is biopsying just one lesion so you only code 1 unit of the CPT.

• When multiple lesions are addressed with FNA biopsy during the same encounter and all lesions are biopsied using the same type of imaging guidance, you report the primary code for the first lesion biopsied and report the add on code for the second and all additional lesions. For example, if a surgeon performed an FNA biopsy of a nodule in the right thyroid under ultrasound guidance and that same surgeon during the same encounter performs an FNA biopsy of a second nodule in the right thyroid also under ultrasound guidance, you will code CPT 10005 for the first nodule and CPT 10006 for the second nodule.

• When multiple lesions are addressed with FNA biopsy during the same encounter but lesions are biopsied using different types of imaging guidance, you report the primary code for the first lesion biopsied, picking the primary code that accurately describes the type of imaging guidance used, and then you report a second primary CPT code for the additional lesion biopsied using a different type of imaging guidance. Modifier 59 (or modifier XS if your payer like Medicare accepts the EPSU modifiers) will be required on the second primary CPT code to indicate that more than one site was biopsied. For example, if a surgeon performed an FNA biopsy of a nodule in the right thyroid under ultrasound guidance and that same surgeon during the same encounter performs an FNA biopsy of a second nodule in the right thyroid under fluoroscopic guidance, you will code CPT 10007 for the nodule biopsied using fluoroscopic guidance and CPT 10005 with modifier 59 (or modifier XS if the payer like Medicare accepts the EPSU modifiers) for the second nodule biopsied under ultrasound guidance. The coding is changed in this scenario because each nodule was biopsied using a different type of imaging guidance. Coding tip: I decided which CPT code needed the modifier 59 based on the NCCI edits. The modifier 59 would go on the column 2 code (i.e., the potentially bundled code in the NCCI edit pair). You can download a copy of the NCCI edit tables from Medicare’s website at the following link: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html. When you get to the website, download all files that start with “Practitioner PTP Edits v25.0” (there are four files in total). You can also check edits in online coding software like 3M, Encoder Pro, and Supercoder (many coders find this to be an easier method of checking their edits). Just be sure to apply the modifier 59 (or XS) to your column 2 code.

I hope this article helps you to understand the changes for these codes in 2019 and how to use these codes correctly. If you have any questions about this topic or any of the new 2019 CPT codes that you would like to hear more about, head over to the “contact” tab and send me your question. I am always happy to hear from my readers and provide content that will help you in your daily work.

Many times when I’m working with coders and refer to a guideline that lead me to my conclusion on how to code a specific procedure, the coder will ask me how they can find the guidelines I’m referencing for themselves. One of the first keys to being a successful coder is building your library of coding resources that will help you along the way. This article is dedicated to sharing with you all some of the resources that help me with my daily work.

• The CPT guidelines: While this may seem like an obvious one, it’s amazing how many times I see a coder make an error on a case because they weren’t aware of the CPT guidelines for that code. The CPT guidelines include the paragraphs of information that appear before a particular range of CPT codes or the parenthetical guidelines that might appear underneath different codes throughout the manual to guide us on appropriate use of the codes. The paragraphs of information throughout CPT often provide key definitions to help us better understand the intent of the codes while the parenthetical guidelines usually provide key rules for how the codes should be used (e.g., notes telling us to code also a second CPT to represent two procedures commonly performed together or to refrain from coding two CPT codes together based on the rules of use for that code).

• The Coder’s Desk Reference: The Coder’s Desk Reference is an Optum product that provides lay descriptions for all CPT            codes. These lay descriptions provide an explanation of that particular code and the procedures that would be included in that code from the start of the procedure to the end of the procedure in easy to understand language. For example, CPT 49560 which is for open repair of an initial ventral or incisional hernia describes how the physician makes an open incision overlying the hernia, reduces or removes the hernia sac, closes the facial defect (the hernia defect itself), and then closes the abdominal wall in layers. The goal of this resource is to help surgery coders specifically know if they are picking a code that accurately reflects the procedure their surgeon performed (the coder is able to “line up” some of the language from the operative report with the language in the lay description to see if the two are a match). This tool can also be helpful to understanding what parts of a procedure are integral  (meaning they are a routine part of the procedure and should not be coded with an additional CPT code(s)). The Coder’s Desk Reference is available for purchase as a stand-alone product through the publisher Optum: Coder’s Desk Reference. It is also available through other third-party websites and is often offered as part of coding software packages such as Optum Encoder Pro or Supercoder.

• CPT Assist:  CPT Assistant (known as CPT Assist for short) is a publication from the American Medical Association (AMA). The AMA is the governing body that publishes the CPT manual each year. CPT Assist is a publication where the AMA answers frequently asked questions from coders and physicians or where they explain guidelines for CPT codes/topics that aren’t abundantly clear in the CPT manual. Often, the AMA will answer a coding question and also provide a clinical vignette to illustrate the correct use of the CPT code. This publication is available for direct purchase from the AMA: CPT Assist. It is also available as an add on module for purchase as part of coding software packages such as Optum Encoder Pro.

• NCCI Edits: The National Correct Coding Initiative (NCCI) edits are published by Medicare each quarter (in January, April, July, and October). The purpose of the NCCI edits is to prevent inappropriate reporting of procedures that are considered a routine part of the main procedure being performed. When coders and physicians report multiple CPT codes when one or more of those codes is considered a routine part of the main procedure, the practice is know as unbundling. While the NCCI edits are a Medicare product and Medicare Administrative Contractors processing claims will always follow the NCCI edits, many commercial carriers also follow the NCCI edits (you may find some small payers that do not follow NCCI and develop their own editing policies, but those payers are growing more rare as NCCI has become a nationally-accepted standard for correct coding and referenced by many non-Medicare payers). You can usually check your payer contracts to see if they are following NCCI or find this information through a simple Google search (e.g., “does United Healthcare follow NCCI edits?”) The NCCI edit tables can be downloaded from the Medicare website each quarter:  NCCI Edit Tables. These edits can also be checked in coding software such as Encoder Pro and Supercoder which offer built-in CCI edit check tools.

• NCCI Policy Manual: The NCCI Policy Manual is a tool designed to be used in conjunction with the NCCI edit tables. This policy manual is published by Medicare and updated each January. The NCCI Policy Manual explains the reason for many of the edits that exist in the NCCI edit tables. The policy manual also explains certain correct coding rules for which no edits exist. The introduction chapter to the NCCI policy manual states that the NCCI edit tables are designed to represent the most common forms of unbundling that exist, but even in the absence of an NCCI edit, providers and coders are expected to code correctly. To explain that statement further, it is not good enough to simply check your NCCI edits and report two codes together simply because no edit exists. You must consider all coding guidelines and policies including the CPT guidelines and the rules outlined in the NCCI Policy Manual in your coding. The NCCI Policy Manual is available for download from the CMS website: NCCI Policy Manual. The current manual is titled “NCCI Policy Manual for Medicare Services – effective January 1, 2018” and can be found in the “downloads” box once you arrive at the website.

• CMS Modifier 59 Article: As important as it is to know whether an NCCI edit exists between two codes, it’s equally important to know why that edit exists and when it would be appropriate to bypass the edit with a modifier 59 or one of the new EPSU modifiers from Medicare (I will talk more about these EPSU modifiers in a future article). The CMS Modifier 59 Article is a key resource to understanding NCCI edits and when you would and would not bypass those edits. The article stresses the fact that just because the edit between two codes allows for a modifier to bypass the edit does not mean you should automatically do so.
  The article also provides some helpful examples of when you could unbundle two codes in an NCCI edit pair. This article is available for download from the CMS website: Modifier 59 Article. When you arrive at the website, scroll down to the downloads box and click on “Modifier 59 Article: Proper Usage Regarding Distinct Procedural Services – Updated 11/15/17.”

• CMS Examples of NCCI Edits: Another great resource I found from CMS is a 49 page document explaining different reasons NCCI edits may exist and giving clinical examples of those types of edits and appropriate coding. Each NCCI edit is assigned a “reason” for potential bundling in the NCCI edit tables (e.g., standards of medical/surgical practice, more extensive procedure, misuse of a column 1 with a column 2 code, etc.). Each of these reasons has a specific definition in CMS policy and helps us to better understand why the edit exists which in turn can help us know when to bypass the edit and when the edit actually applies to our report and scenario and should not be bypassed. This tool is available for download from the CMS website at the following link: NCCI Edit Examples

• CMS Claims Processing Manual Chapter 12: The CMS Claims Processing Manual contains many of the guidelines that Medicare Administrative Contractors (MACs) apply when they are processing claims. Chapter 12 is particularly helpful for surgery coders because it contains the rules for co-surgery, assistants at surgery, billing for mid-level providers (NPs/PAs), teaching facility rules where physicians involve residents in their surgeries, and many other surgery-specific topics. This resource is available for download from the CMS website: Claims Processing Manual.

• Medically Unlikely Edits: The Medically Unlikely Edits (MUEs) are also published by Medicare each quarter (in January, April, July, and October). These edits let providers and coders know how often a code is typically expected to be billed by the same physician providing care to the same patient on the same date of service. In addition to looking at the MUE itself which tells you how many times a code would generally be reported on the same date by the same provider, you should also check the MAI indicator (which is the reason the MUE edit exists). This indicator is also referred to as the MUE rationale and lets you know when you may exceed the MUE for a particular code and when the edit is binding. The three MAI indicators for MUE edits are as follows:

1 – Line item edit: This type of edit represents the maximum number of units of a code that may be reported on a single line on a claim. To bypass this edit if you need to report units in excess of the MUE, report the code on more than one line of the claim and link the maximum number of units allowed by the MUE to each line of the claim. For example, if you are reporting a code with an MUE of 3 and an MAI indicator of “line item edit,” and you need to report 6 units of the code based on documentation report the code once on the first line of the claim with units of 3 and then report a second line of code with the same CPT and the remaining 3 units.

  2 – Date of service edit: This type of edit represents the maximum number of units of a code that may be reported by the same  physician for the same patient on the same date of service. These edits are considered “binding” on providers and contractors     processing claims based on anatomy or the definition of a code. In other words, you absolutely cannot code in excess of the MUE for a code with this MAI indicator (to do so is considered a coding error per Medicare guidelines).

 3 – Date of service edit: This type of edit represents the maximum number of units of a code that Medicare expects to be reported by the same physician for the same patient on the same date of service. This edit is similar to the MAI indicator of 2, but unlike that edit, this type of MUE edit may be exceeded when documentation supports coding in excess of the MUEs for a particular CPT code(s). Be prepared to submit documentation supporting the fact that exceeding the MUE for the code is appropriate since Medicare views reporting more units than that typically allowed to be the exception not the norm.

The MUE edit tables which contain the MUEs and the MAI indicators is available for download from the CMS website: MUE Edit Tables. When you arrive at the website, scroll down to the “downloads” box and click on the Practitioner MUE tables link for the current quarter.

I hope you find these resources helpful! How about you – what coding resources do you find helpful when coding surgical and diagnostic procedures? Share your favorite resources in the comments. Coding is a team sport, and you never how a great resource you have discovered might help a fellow coder.

Last year we saw some notable changes to coding for diagnostic and therapeutic procedures performed in arteriovenous fistulas and grafts. Nine new procedure codes for percutaneous procedures performed in arteriovenous fistulas and grafts were created in 2017.

Before we look at the individual CPT codes and what procedure each one represents, it’s important to understand some key terms/definitions in the CPT manual that will help us understand the codes and apply them correctly:

• Arteriovenous fistula: An intentional connection between an artery and a vein that is surgically-created to allow a patient to receive dialysis. The point at which the artery and the vein connect is known as an anastomosis. 
• Arteriovenous graft: Placement of a piece of vein from the patient’s own body or synthetic material (e.g., PTFE) to intentionally connect an artery and a vein to allow a patient to receive dialysis. With an arteriovenous graft, there are two anastomoses – one to the artery on one end of the graft and the other to the vein on the other end of the graft.
• Arterial anastomosis: In an arteriovenous fistula, this is the single anastomosis between the artery and the vein. In an arteriovenous graft, this is the anastomosis between the artery and the one end of the graft attached to the artery. 
• Dialysis circuit: A term used in CPT interchangeably to refer to an arteriovenous fistula or an arteriovenous graft. The dialysis circuit begins with the arterial anastomosis and ends where the superior or inferior vena cava are connected to the right atrium of the heart.
• Peripheral segment: The part of the dialysis circuit that begins with the arterial anastomosis and continues through the entire axillary vein or cephalic vein for a dialysis circuit in the arm (whether the termination point of the peripheral segment is the end of the axillary vein or the cephalic vein will depend on the vein involved in the arteriovenous fistula or graft). For example, if the basilic vein is connected to an artery to form an arteriovenous fistula, the venous outflow will be the axillary artery. If you are a visual learner like me, check out this picture of the veins of the arm to help you visualize and understand all the anatomy of these vessels and how far the peripheral segment would extend: Picture of Arm Veins. In rare cases where the dialysis circuit is placed in the leg, the peripheral segment begins at the arterial anastomosis and continues through the entire common femoral vein: Picture of Leg Veins
• Central segment: The part of the dialysis circuit that begins with the central veins (the subclavian and the innominate veins) and continues through the superior vena cava to the right atrium of the heart for a dialysis circuit in the arm. In rare cases where the dialysis circuit is placed in the leg, the central segment begins with the iliac veins then continues through the inferior vena cava to the right atrium of the heart. Again if you are a visual learner, check out this link which shows the connection between the inferior and superior vena cavas and the right atrium of the heart to help you visualize how far the dialysis circuit continues (all the way into the chest until these major veins empty into the heart): Termination Point for Dialysis Circuits.
• “In/through the dialysis circuit”: The coding guidelines and examples you may see from coding consultants will often make reference to using the codes we will discuss today for a procedure performed “in” or “through” the dialysis circuit. A procedure performed “in/through” the dialysis circuit is any procedure (e.g., angioplasty, stent, etc.) performed by placing a needle(s) or catheter(s) into a structure that is part of the dialysis circuit. Again, the dialysis circuit runs from the arterial anastomosis to the juncture where the inferior or superior vena cava joins the right atrium of the heart so if a needle or catheter is inserted in any point along this track, the procedure is stated to be performed “in/through the dialysis circuit.”
• Peri-anastomotic region: The portion of the dialysis circuit that includes a small part of the native artery immediately adjacent to the arterial anastomosis where that artery is joined to a vein or the end of a graft to form a dialysis circuit; the anastomosis itself; and the part of the vein/graft immediately adjacent to the arterial anastomosis. Any interventions performed in this region even if they are in the small segment of the native artery adjacent to the arterial anastomosis are considered “in the dialysis circuit” and may not be reported separately.

Now that we have established some of these key terms, let’s take a look at the codes themselves to see what each one includes. These first six codes are progressive hierarchal codes (codes where each code in the series includes the work of the code(s) that preceded it). This concept is important to understanding how these codes are used when multiple procedures occur in the same dialysis circuit.

CPT 36901 is the first code in the series and is used to report a diagnostic fistulogram. This procedure involves introducing a needle or catheter into the fistula/graft, injecting dye, and then obtaining images of the dialysis circuit. Physicians may use the term “angiogram” to describe a fistulogram. An angiogram is an image of a blood vessel(s) taken after introduction of dye to allow the physician to view the blood vessel and when this procedure occurs in/through a dialysis circuit, the term angiogram and diagnostic fistulogram are synonyms. This procedure can be helpful to diagnose complications of the dialysis circuit such as clot, stenosis, or pseudoaneurysm. This code includes introducing one or more needles/catheters into the dialysis circuit, the injection of contrast, the work of obtaining images, and the physician’s interpretation. This code includes obtaining and interpreting images in the peripheral and central segments of the dialysis circuit as necessary (the exact images obtained and commented on by the physician will depend on the patient’s symptoms and the area of the dialysis circuit that is of concern).

CPT 36902 is the second code in the series and is used to report an angioplasty in the peripheral segment. An angioplasty involves inserting a small balloon which is inflated to open up an artery/vein so blood can flow through it freely. This code includes the work of introducing one or more needles/catheters into the dialysis circuit to perform the angioplasty procedure. If more than one angioplasty is needed in the peripheral segment, CPT 36902 is reported only once to capture all angioplasties in the peripheral segment. Also, because these first six codes are progressive hierarchal codes , if a diagnostic fistulogram is needed in addition to the angioplasty, the fistulogram is also included in this code. Coders should not report both 36902 and 36901 together when these procedures are performed in the same dialysis circuit.

CPT 36903 is the third code in the series and is used to report a stent placement in the peripheral segment. A stent is a tube-like device that can be inserted into an artery or vein and expanded to provide support for the walls of the artery or vein and keep them open so blood can flow through the vessel freely. This code includes the work of introducing one or more needles/catheters into the dialysis circuit to perform the stent procedure. If more than one stent is needed in the peripheral segment, CPT 36903 is reported only once to capture all stents in the peripheral segment. Also, because these codes are progressive hierarchal codes, if an angioplasty in the peripheral segment and/or a diagnostic fistulogram are also needed in addition to the stent, the angioplasty and/or fistulogram are also included in this code. Coders should not report CPT 36903 with 36902 and/or 36901 when these procedures are performed in the same dialysis circuit.

CPT 36904 is the fourth code in the series and is used to report percutaneous procedures to remove blood clots (aka thrombus) from the dialysis circuit. Unlike the codes we’ve talked about to point, this procedure code covers clot removal from the entire dialysis circuit (peripheral segment and/or central segment as needed). Methods for removing these blood clots can include mechanical thrombectomy which involves inserting a catheter with a device that breaks up clots and allows them to be removed. They may also include infusions like a TPA infusion to dissolve the clots. This code includes the work of introducing one or more needles/catheters into the dialysis circuit to perform the percutaneous clot removal procedure. Also, because these codes are progressive hierarchal codes, if a diagnostic fistulogram is needed in addition to the percutaneous clot removal procedure, the fistulogram is also included in this code. Coders should not report 36904 and 36901 together when these procedures are performed in the same dialysis circuit. If a percutaneous clot removal procedure occurs in addition to a peripheral segment angioplasty or stent, there are combination codes for that (see CPT 36905 and 36906 below). Do not report 36904 with 36902 and/or 36903 in the same dialysis circuit.

CPT 36905 is the fifth code in the series and is used to report percutaneous procedures to remove blood clots plus an angioplasty procedure in the peripheral segment of the dialysis circuit. This code includes the work of CPT codes 36902 and 36904 combined. Because these codes are progressive hierarchal codes, if a diagnostic fistulogram is needed in addition to the percutaneous clot removal and angioplasty procedures, the fistulogram is also included in this code. Coders should not report 36905 and 36901 together when these procedures are performed in the same dialysis circuit. Again coders also should not report 36904 and 36902 together when percutaneous clot removal and peripheral segment angioplasty are performed in the same dialysis circuit (this one combination code 36905 represents the work of those two codes together).

CPT 36906 is the sixth code in the series and is used to report percutaneous procedures to remove blood clots plus a stent placement in the peripheral segment of the dialysis circuit. This code includes the work of CPT codes 36903 and 36904 combined. Because these codes are progressive hierarchal codes, if a diagnostic fistulogram and/or an angioplasty in the peripheral segment are needed in addition to the percutaneous clot removal and stent procedures, the fistulogram and/or angioplasty are also included in this code. Coders should not report 36902, 36905, or 36901 with CPT 36906 when these procedures are performed in the same dialysis circuit or report those individual codes together. This one code includes all the work described by those codes combined.

Unlike the codes we’ve talked about to point, the next two codes represent procedures performed in the central segment of the dialysis graft:

CPT 36907 is the seventh code in the series and is used to report an angioplasty in the central segment. Just like CPT 36902, this procedure involves inserting a small balloon which is inflated to open up a vein so blood can flow through it freely. The only difference between these two codes is that CPT 36902 represents this work in the peripheral segment while CPT 36907 represents this work in the central segment. Because CPT 36907 represents work in a different segment of the dialysis circuit, this code may be reported in additon to CPT codes 36901-36906. In fact, CPT 36907 is an add on code which means it may never be reported by itself. You must first report a code from CPT range 36818-36833 or a code from CPT range 36901-36906.

CPT 36908 is the eighth code in the series and is used to report a stent placement in the central segment. Just like CPT 36903, this procedure involves inserting a tube-like device into a vein which is expanded to provide support for the walls of the artery or vein and keep them open so blood can flow through the vessel freely. The only difference between these two codes is that CPT 36903 represents this work in the peripheral segment while CPT 36908 represents this work in the central segment. Because CPT 36908 represents work in a different segment of the dialysis circuit, this code may be reported in addition to CPT codes 36901-36906. In fact, CPT 36908 is an add on code which means it may never be reported by itself. You must first report a code from CPT range 36818-36833 or a code from CPT range 36901-36906.

The ninth and final code in the series represents work that may occur in one or both segments of the dialysis circuit or in accessory veins connected to and accessed through the dialysis circuit.

CPT 36909 is reported for vascular embolization or occlusion that occurs in the main dialysis circuit itself or in the accessory veins (small veins connected to the dialysis circuit that can cause lower blood flow in the dialysis circuit). A vascular embolization or occlusion involves placing devices such as coils, beads, or other vessel blocking devices to completely occlude an accessory vein and/or to partially occlude a vein and improve flow in the dialysis circuit. This code includes the work of placing one or more needles and/or catheters into the dialysis circuit and introducing one or more of these vessel occluding devices into the circuit itself or into the accessory veins. This code is reported only once per dialysis circuit regardless of how many vessel occluding devices are placed. CPT 36909 is an add on code and can never be reported by itself. We must first report a code from CPT range 36901-36906 in order to report this code.

Okay time to put these codes and definitions into action with some examples.

Example 1: A 76 year old patient presents with a non-functioning arteriovenous fistula.  A fistulogram with possible intervention is recommended. The right arm was prepped and draped, and a 21 gauge needle was introduced into the cephalic vein just beyond the arterial anastomosis. An angiogram was performed showing a widely patent fistula throughout the peripheral segment. In the innominate vein, a high-grade stenosis was observed. Therefore, a 6 french sheath was threaded from the cephalic vein to the level of the observed stenosis, and angioplasty was performed. A completion angiogram revealed improved flow and no further stenosis in the innominate vein. The sheath was withdrawn and pressure applied to ensure control of bleeding. The patient was transferred to recovery in stable condition.

Answer Example 1: In this example, we see the physician start off by introducing a needle into the dialysis circuit (he’s in the cephalic vein just beyond the arterial anastomosis in the peripheral segment). He then performs a diagnostic fistulogram (he uses the word “angiogram” but remember an angiogram is just a picture of a blood vessel taken after dye is injected so the physician can see the blood vessel and when this procedure occurs in a dialysis circuit, it’s known more specifically as a diagnostic fistulogram). He then provides us with his interpretation of that diagnostic fistulogram. The peripheral segment is patent – all blood vessels are open with normal flow. The innominate vein which is in the central segment has a high-grade stenosis – a significant area of narrowing in the blood vessel. He then introduces a sheath (aka a catheter) and threads that to the level of the observed stenosis (in the innominate vein) and performs an angioplasty. This angioplasty in the innominate vein is in the central segment.  Our code for the angioplasty is CPT 36907  since the angioplasty occurs in the central segment. Because CPT 36907 is an add on code, we will report the work that occurred during the diagnostic fistulogram first with CPT 36901 so we have our primary CPT code and then report the add on code 36907 for the central segment angioplasty.

Example 2: A 54 year old patient presents with a non-maturing fistula. Her nephrologist is concerned she may have large accessory veins causing poor flow in her fistula. The patient is brought in for a fistulogram to better assess the anatomy and determine next steps. After sterile prep and drap, a 21 gauge needle is used to enter the basilic vein in the left arm. Dye is introduced and images obtained. Fistulogram reveals the presence of multiple large collateral veins causing abnormally low flow in the dialysis circuit throughout the peripheral segment. A 5 French sheath is introduced, and one at a time, each of these large collateral veins were selectively engaged and embolization coils placed. A completion fistulogram shows improved flow in the circuit and the decision was made to terminate the procedure. The patient was wheeled to recovery in stable condition.

Answer Example 2: In this example, we see the physician start off by introducing a needle into the dialysis circuit (he’s in the basilic vein in the peripheral segment of the dialysis circuit). He then performs a fistulogram (this time he actually uses the term fistulogram but angiogram would have been an acceptable synonym here as well). He introduces dye and obtains images of the dialysis circuit (here is describing the steps of performing the fistulogram). He then provides an interpretation that there are multiple large collateral veins causing poor flow in the fistula. Note that “collateral veins” is a synonym for “accessory veins.” Once he’s identified these collateral veins as the cause of the problem in the fistula, he threads a catheter into each collateral vein and places “embolization coils” (which are a type of vessel occluding device). He then notes improved flow in the fistula. We will report CPT 36909 for the placement of the embolization coils. Even though he places more than one coil, we report CPT 36909 only once for all vessel occlusion devices placed in the same dialysis circuit/accessory veins of that dialysis circuit. Because CPT 36909 is an add on code and may not be reported by itself, we will also report CPT 36901 for the diagnostic fistulogram at the start of the case which gives us a valid primary code for our add on code 36909.

Example 3: A 61 year old patient presents with complaints of poor flow in her AV graft during recent dialysis. A diagnostic fistulogram was performed in radiology yesterday revealing a high grade stenosis in the graft body as well as in the axillary vein. The patient also has thrombus at the arterial anastomosis. The decision was made to bring her to the OR today for thrombectomy and stent placement.

After sterile prep and drape, a small puncture was made overlying the graft just distal to the arterial anastomosis. A catheter was introduced and mechanical thrombectomy was performed disrupting the known clot at the arterial anastomosis. The catheter was then threaded towards the venous side of the graft in the area of the previously identified stenosis. Balloon angioplasty was performed followed by placement of a Viabahn stent. Finally, the catheter was threaded up the venous outflow the area of previously identified stenosis in the axillary vein. A balloon angioplasty was performed to open up the venous outflow. A completion angiogram was obtained showing no evidence of further clot or stenosis. This concluded the procedure, and the patient was transferred to recovery in stable condition.

Answer Example 3: In this case, the physician starts off by giving us the results of a recent fistulogram performed by the interventional radiologist so he is not personally performing the fistulogram. Based on those results, he’s already decided to perform a thrombus removal and stent placement. He starts off by introducing a catheter into the dialysis circuit in the graft body itself (which means the puncture and subsequent catheter placement was directly into the piece of graft connecting the artery and the vein over in the peripheral segment). He then begins with a mechanical thrombectomy at the arterial anastomosis to break up the clot. After completing the mechanical thrombectomy, he moves further into the graft closer to where it connects to the vein and finds the area of stenosis where he performs a balloon angioplasty followed by placement of a stent. Finally, he moves further up the venous outflow of the dialysis circuit into the axillary vein where he does one final balloon angioplasty of an area of stenosis. Note that he is still in the peripheral segment with this last procedure since he is in the axillary vein. So all of the procedures in this case are in the peripheral segment and they include mechanical thrombectomy plus a stent placement plus two balloon angioplasties. This documentation supports CPT 36906. This one combination code includes a thrombus removal plus a stent placement in the peripheral segment. Also because these codes are progressive hierarchal codes the angioplasties which both occur in the peripheral segment are included and may not be reported separately.

These cases illustrate some common percutaneous procedures you may encounter in AV dialysis circuits. Be sure to check back for our next article as well where we will discuss some challenges of coding AV dialysis circuit procedures when some procedures are performed through a percutaneous approach (the procedure codes we have discussed here) and some are performed through an open incision overlying the dialysis circuit. We will also talk about how to code cases where percutaneous procedures occur in the dialysis circuit but the approach to the procedure is through puncture of a blood vessel outside of the dialysis circuit which changes your CPT codes.