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Coding Q&A
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Coding Q&A


Q:   We are placing a tunneled catheter through an existing venous access and we are creating another access for the patient for the catheter. How should I be coding this procedure?

A:  “36581 is the CPT code for replacement, complete of a tunneled centrally inserted central venous catheter, without subcutaneous pot or pump, through same venous access. This “catheter exchange” procedure technique has been described utilizing the same subcutaneous tunnel and exit site or by creating a different tunnel exit site. The tunnel and exit site are not pertinent – if the same venous access site is used then the 36581 replacement code is correct.”

We had a case where we did not perform the angiogram because we were not able to put the wire through and we were not able to declott the patient either. But we just did the cannulation so how do I code those cannulations?
 A: This case would need to be coded with 36147 with a 52 modifier to indicate reduced level of service.  In filing the claim it is important to provide documentation as to what was done. 

Q:   We had a patient who came for complete thrombectomy procedure on Monday and we were able to declott the patient, finish the procedure successfully and send patient home. The very next day patient re-clotted and we had to bring back the patient for declotting again- how do we code for the next day?
A: This should be coded as a thrombectomy with a modifier. As to which modifier to use, it would depend upon the following:
         1.      If it reclotted because of a poorly done or incomplete initial procedure then it falls within the global period then use a 78
         2.      If the reclotting is due to an external factor such as hypotension, etc then use 79
12.6 Subsequent Procedure Performed During Global Period
A number of the procedures that are performed have global periods (Table 18). This means that if a repeat procedure is performed during that period, it is not covered. However, there are times when it becomes necessary to perform an identical or similar procedure on a patient subsequent to a procedure with a global period that has not yet expired. There are several modifiers that have been used to report and code this situation so that coverage will be available. The terminology attached to these modifiers appears to be surgical. When dealing with surgical cases, the appropriate choice of a modifier may be obvious. However, in the case of endovascular procedures it becomes somewhat confusing. There are patients who experience a thrombosed graft within a relatively short period after a previous thrombectomy. In one instance this may be due to recurrent hypotension and totally unrelated to the previous procedure; however, it is not totally clear from the descriptors whether this would be classified as a repeat procedure or an unrelated procedure.
The choices of modifier to attach to the basic identifying code when a subsequent procedure is performed during the global period include 76, 77, 78 and 79. The modifier - 76 is used to indicate a repeat procedure by the same physician and modifier - 77 is use to indicate a repeat procedure performed by another physician. The terminology used in the descriptions for these codes suggest that they would be the best choice if it was apparent that the subsequent procedure was totally unrelated to the previous one. The modifier - 78 has a descriptor that suggests its use when the subsequent procedure was related to the previous one. Based upon its description, use of the modifier - 79 seems to be warranted in cases where the subsequent procedure is completely different from the previous one, neither repeated nor related.  

Q: Our coders are of the opinion that billing for subsequent hospital care after placement of a dialysis access falls under the global billing rules. This does not seem correct. Is there a diagnosis or cpt/modifier to clarify that the access placement was for the subesequent (dialysis) care and not the other way around? We are a new practice and our coders are not familiar with interventional nephrology, but it makes no sense that by doing an interventional procedure you would no longer be able to bill regular nephrology-type charges. Please help.
A: If the procedure is performed in an outpatient setting the place of service will be different from both of these. Therefore, there is no problem filing the 99232. If the procedure is performed in the hospital, there will be a problem because of the POS. An appeal could be made but probably would not be worth the costs.

 However, commonly in the hospital, we will see the patient (initial visit or ongoing care), place a catheter for acute and chronic renal failure, and then perform dialysis – all on the same day. While we cannot bill for both the EM service and dialysis service, we bill for the catheter placement with the higher coded visit (dialysis or EM).

The following (excepted from CMS claims processing manual) is the relevant coding guideline for this question: 

160.2 - Physicians’ Services Furnished on Day of Dialysis
(Rev. 1, 10-01-03)
Supervision or direction of a dialysis treatment by a physician does not ordinarily meet the requirements for physicians’ services and, therefore, is not paid for as such under the fee schedule. However, physicians are responsible for the medical care and treatment of the dialysis patients. Physicians’ services furnished to those patients that meet the requirements and are medically necessary are covered. The hospital medical record must document the services furnished and the medical reasons for them.

Generally, claims from the physician receiving a procedure code payment for additional services furnished to the same patient on the day of dialysis must be reviewed by medical staff prior to payment. Follow §170.B for dialysis and evaluation and management services performed on the same day.

Payment in addition to the procedure code payment is made only if the service is not related to the treatment of the patient’s ESRD, and the service was not, and could not have been, furnished during the dialysis treatment. However, an exception to this rule is physicians’ surgical services; e.g., catheter insertion. Physicians’ surgical services are generally billed under the appropriate procedure code for payment. If more than one physician furnishes care to the same dialysis patient, follow the usual coverage rules on concurrent care. 

We interpret this to say that the procedure (catheter insertion) can be billed with the dialysis visit or the EM visit on same day by same physician or another in the group practice. However, you cannot bill dialysis and EM on the same day in the hospital patient.

Q: I need to have a clearer understanding about Interventional Nephrologist reading and billing ESRD Vein Mapping Procedures to CMS.
1. What specific formal training must an Interventional Nephrologist go through in order to meet CMS billing requirements for performing and reading Vascular Ultrasounds? Are there specific requirements that the IN must have in order to be within CMS billing guidelines?
2. If the Interventional Nephrologist is certified to perform and read studies, does the actual scanning portion of the procedure need to be performed by a Registered Vascular Technologist or the IN, or could the certified IN train additional personnel to perform these studies (for example and Registered Nurse/Radiologic Technologist/Medical Assistant).
A: There may be some state specific requirements; however, from CMS viewpoint any physician can perform a vascular mapping and read it. If it is done by a technician, then they must be a certified ultrasound technician.

Q:  Our coders are of the opinion that billing for subsequent hospital care after placement of a dialysis access falls under the global billing rules. This does not seem correct. Is there a diagnosis or cpt/modifier to clarify that the access placement was for the subsequent (dialysis) care and not the other way around? We are a new practice and our coders are not familiar with interventional nephrology, but it makes no sense that by doing an interventional procedure you would no longer be able to bill regular nephrology-type charges.
A:  Most interventional nephrology procedures do not have an associated global period so there is no issue with billing an E&M code on subsequent days. However, if the procedure performed by the nephrologist has a subsequent global period (thrombectomy, fistula placement, etc) then a modifier is required to bill for an E&M service during the global period. The modifiers to use in this situation are:

24 – unrelated evaluation and management service by the same physician during a postoperative period
25 – (less common) – significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service
The modifier is required if the same physician who did the procedure is providing the E&M service, or if a physician within that same practice is providing the service. No modifier is required to bill the monthly HD capitation service and no modifier is required if a surgeon performed the procedure.

Q:  Having trouble coding the following scenario:
Patient with a thrombosed radiocephalic AV fistula.  The fistula was ligated within several centimeters of the AV anastomosis.  The aneurysmal segment was then excised, and the vein was ligated proximally.  A brachial to brachial vein AV fistula was then created.
Is this coded as a ligation of the radiocephalic AV fistula (CPT 37607) and creation of a new AV fistula (CPT 36821)?
A:  In my view that would be the appropriate coding for the case with the appropriate -59 modifier
The radial;-cephalic fistula was ligated -- 1 procedure
A brachial-brachial fistula was created – 2nd procedure
Since these are in separate anatomical areas, I would interpret as separate procedures

Q:  Once a coil is deployed and if it migrates and we need to snare it to retrieve, does one not then charge for the deployed coil? My understanding is that the billing is not per coil deployed but more the vessel that is closed.
A:  Yes you can charge for the coil placement since it was done

Q:  We have a patient who came in for Venous Angioplasty and had Angiogram done also but we had 2 complications.... Thrombectomy performed but unsuccessfully because 1) rupture was contained and 2) clot off the access.  How should one code it? What modifier?
A:  I would code the 36147, the 35476/75978. The 75870 needs 52 modifier with clear explanation of how much of the thrombectomy was performed.

What if you attempt a procedure and cannot do it? How should it be properly coded? These are important questions. Basically, you should always code for what was actually accomplished. Beyond this, you have three choices.
12.2.1 Code Only the Procedure Completed
One could choose to code only what was completed and omit any codes for what was attempted and not accomplished. For example if one started out to do an angioplasty, but could not pass a guidewire and decided to stop after the initial angiogram, you could simply code it as a cannulation and a venogram using the 36147 code. This would be a reasonable choice since that is all that was actually accomplished.
12.2.2 Modifier for Reduced Level of Service
One could use a modifier to indicate that the basic service was altered. The modifier, -52, could be used to signify that the basic coded service has been reduced. This is designed to be used in circumstances where a service or procedure is partially reduced or eliminated. The use of this modifier allows one to report reduced services without disturbing the identification of the basic service. For example, if angioplasty was attempted, but after multiple tries with several types of guiding catheters and different guidewires, you could not get the guidewire across the lesion. In this instance the treatment could not be completed. A reasonable choice would be to code the procedure as 35476-52 and 75978-52 to indicate a reduced level of service. The other codes for procedures or services that were completed would be coded normally. Your report would be individually reviewed by the intermediary to determine a payment level. This would be a percentage of the basic fee. For this reason, documentation becomes very important to form a basis for this determination.
12.2.3 Modifier for Discontinued Procedure
One could use a different modifier to indicate that the procedure was discontinued. This modifier is -53. The use of this designation indicates that the procedure was started but discontinued. It could be used as an alternative to the -52 designation in the example quoted above.

Q:  We brought patient to do angioplasty and angiogram on a particular day but did not finish the angioplasty. We only finished angiogram and that also not complete. Now we brought the patient back on the different day to finish the angioplasty and made sure the angiogram looks good or not? So how do I code the first angiogram and then the angioplasty.... what modifier should I have used on the first visit and what modifier can I use now on the second visit
A:  My personal inclination would be to not code the first study since it was not complete.  However, it would be dependent upon the reason for the incomplete study.  If there was a medical indication for stopping on the first day and then going back and completing, code a cannulation and angiogram on the first day 36147.  On the subsequent day code 36147 plus the angiogram 35476/75978 I would emphasize the need for careful documentation as to why the pta was not completed at the initial procedure.

Q:  I was trying to find out if I can code and bill insurance for a removal of non-tunneled dialysis catheter and if so what would be the CPT code because I see CPT codes for removal of central venous access device only
A:  Please refer to the Section 7 of the ASDIN Coding Manual on Non-tunneled catheters.   On page 40, the coding manual states – For non-tunneled catheter removal there is no code available. The CPT Coding Manual clearly states that the codes for removal of tunneled catheters should not be used. 

Q:  3.2 Use of ultrasound to assist dialysis access cannulation
In some instances the cannulation of the dialysis access is very difficult to accomplish. This is particularly true in the case of new or failing AVF. Ultrasound guidance for the cannulation procedure may be required. This is not included in 36147.    The appropriate code for this ultrasound guided access cannulation procedure is +76937. The descriptor for this code is – ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure). This should be listed in addition to the cannulation code 36147 (or +36148). As the descriptor indicates this requires image documentation for the medical record.
What code for the ultrasound guidance can be used if your ultrasound will not record in concurrent realtime and as stated above? Would the use of code 76998 be appropriate? I know that it is a Column 2 code for CPT code 36558 and for 36147, but a modifier is allowed when appropriate.
A:  If I interpret this correctly, the question is –
Since image documentation is required to use the code, what does one do if the US device being used will not record an image?
We have encountered this in the past and the solution we used is as follows
1. If you can’t provide an image, you cannot code
2. If the US device will not record, purchase an inexpensive digital camera and take a picture of the screen and use this as your documentation
3. You should set as a goal replacing the US device with one that will record an image; all of the US procedures that are performed require image documentation. It would very likely be cost effective to obtain a replacement – you have to run the numbers. The basic principle is no image, no code, no payment

(1/12/12) Follow-up
Q:  Our ultrasound machine will record. Just not in concurrent real time. It takes snapshots (15 per ), which we keep on a disk. The way it is described to me sounds like Serialography vs. recording.  My interpretation is it must be like a video to use the 76937 code. Which is why I was asking about code 76998.
A:  No you do not need a video.  Just a single from image (only 1)

Q:  Starting 01/01/2012 code 35475 can’t be used for arterial anastomosis angioplasty. Is it true?
A: Arterial Angioplasty in the Lower Extremity
Coding for a lesion at the arterial anastomosis is unique for the lower extremity. If the lesion is only at the arterial anastomosis, since this is the femoral artery (in most cases), the code 37224 should be used. The descriptor for this code is - revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral; with transluminal angioplasty. This code is from the Lower Extremity Revascularization coding system. In this system the codes are all inclusive. Specifically, the basic cannulation is bundled with the basic procedure code. Therefore in this situation, the code 36147 should not be used (unless a second cannulation is performed). The code 75791 for the angiogram should be used alone. If it is necessary to do a second cannulation then this should be coded 36147 (since this would be the first cannulation requiring an independent code) with a -59 modifier to indicate that this is a separate procedure. When this second cannulation code is used, then 75791 would need to be dropped since it is bundled with 36147. If a third cannulation is required then the 36148 code would be warranted.

If both an angioplasty and a stent are placed, a single code would be used for both. This code would be 37226. Its descriptor is revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed. Supervision and interpretation codes should not be used with these codes.

Note: The Lower Extremity Revascularization coding system includes angioplasty, atherectomy and stent placement. These codes describe revascularization therapies (i.e., transluminal angioplasty, atherectomy, and stent placement) provided in three arterial vascular territories: (1) iliac, (2) femoral/popliteal, and (3) tibial/peroneal. Most of this system does not impact upon dialysis vascular access. However, these vessels are involved with an access located in the thigh. In particular, these cases may develop problems in the iliac and femoral/popliteal territories; it does affect the way these will need to be coded. The series of codes 37220 - +37235 are to be used to describe lower extremity endovascular revascularization services performed for occlusive disease for all vessels of the lower extremity including the arterial portion of the access (anastomosis). These lower extremity codes are built on progressive hierarchies with more intensive services (stenting, atherectomy) inclusive of lesser intensive services (angioplasty). In other words, all of the codes include angioplasty. The code inclusive of all of the services provided for that vessel should be reported (i.e., use the code inclusive of the most intensive services provided). For example if both an angioplasty and a stent placement is performed, then 37221 (stent plus angioplasty) would be reported and 37220 (angioplasty) would not be used.

Diagnostic angiography (arteriogram) is not bundled with the Lower Extremity revascularization codes and can be coded separately unless previously done for the interventional procedure in question. – Arterial and venous combined
If both arterial and venous lesions are present within the access, the same rules as described for the upper extremity would hold. The only difference would be that in this instance the code 37224 would be used rather than 35475 for the arterial treatment.

Q&A prior to 2012 ASDIN/RPA Coding Manual Release

These Q&A are provided here for archive purposes and may or may not be applicable as coding practices change. 

Q:  Some Insurance companies do not accept G0365 for mapping for new patients.  What codes should be used in place?
A:  Thank you for asking the question regarding use of G0365 for preoperative vessel mapping for hemodialysis access planning in new patients. G0365 was specifically developed to be used when performing the procedure you describe. It does have some stipulations as listed in the ASDIN coding manual. If an insurance company is denying payment we recommend that you appeal that decision providing them with evidence of correct coding practice including: CPT 2011 descriptor, relevant part of ASDIN coding manual and relevant directive from your local Medicare Carrier.

Q:  We are looking for coding guidance for thrombolytic infusion of a tunneled dialysis catheter.  Currently we believe we can bill using these codes  37201 and 75896 along with cathflo activase    J2997 in a vascular access center
A:  You asked for coding guidance for “thrombolytic infusion” of a tunneled dialysis catheter and specifically whether 37201/75896 coding is correct. I will refer you to the ASDIN coding manual for details about coding catheter and other procedures. The specific directive in our manual is as follows:

6.5.4 Intraluminal Removal of Catheter Thrombus
If a thrombosed catheter is treated mechanically with an endoluminal brush or guidewire to remove athrombus and restore its function the use of the code 36596 is warranted. The descriptor for this code is -mechanical removal of intraluminal (intracatheter) obstructive material from a central venous devicethrough device lumen. If this is done under fluoroscopic guidance there is a supervision and interpretationcode to accompany it. This code is 75902. The descriptor for this code is - mechanical removal ofintraluminal (intracatheter) obstructive material from a central venous device through device lumen,radiologic supervision and interpretation.6.5.5 Intraluminal lytic enzyme
The instillation of intraluminal lytic enzyme has been extremely useful to the nephrologist in managingcatheter dysfunction within the dialysis facility. With changes in dialysis reimbursement, much of this is nowbeing sent to the interventionalist at the access center. The code for this procedure is 36593. Thedescriptor for this code is - declotting by thrombolytic agent of implanted vascular access device orcatheter. This is a column 2 code to 36596 (mechanical removal of intraluminal obstructive material fromcentral venous device through device lumen). The two codes can be used together with a modifier on thecolumn 2 code. A -59 modifier would be appropriate for this situation.

The most common use of TPA to restore catheter function is via instillation to fill the catheter lumen volume for 30-60 minutes and thereby lyse intraluminal thrombus to restore function. When this is not effective a catheter exchange is indicated as fibrin sheathing may be playing a role which can be addressed at the time of catheter exchange. Actual continuous “infusion” of TPA through the catheter lumen for a period of time has been described in the literature but is not a commonly employed practice today. ASDIN does not have coding recommendation for this practice nor can we comment on the safety or efficacy of this continuous infusion approach in the access center setting at this time.
These 2 codes (37201 and 75896) are definitely not usable for the indications discussed. After reviewing, ASDIN cannot recommend nor support the use of these 2 codes for opening a dialysis catheter.

Q:  There has been much discussion in our group on how to correctly bill for unilateral and bilateral venograms only for vein mapping in patients who have not had an av access before. We do not use ultrasound in conjunction. Can you please give us the proper codes and how the g codes work here.
A:  If the patient has not had a previous fistula or graft, the temporary code G-0365 should be used. In order to qualify for this code, imaging can be done using any technique or combination of techniques. It should be noted that the descriptor for this code specifies that both the venous and arterial anatomy must be evaluated. If only the veins are imaged, a - 52 modifier should be attached to the code to indicate a reduced level of service. The G-0365 code is for one extremity only, if both upper extremities are examined the code should be listed a second time with a – 59 modifier to indicate a separate distinct service. It is important to note that the use of this code is restricted to a patient that has not had a prior dialysis access graft or fistula. Additionally, it can only be used two times a year.
The use of G-0365 does not preclude the use of surgical codes that might be warranted based upon the type of procedure performed. If, for example, the vein mapping portion of the study was performed by angiography, the code 36005 (cannulation of vein and injection of contrast) may be applied.
In the case of a patient who has had a prior arteriovenous dialysis access (graft or fistula), coding for vascular mapping involves the use of a group of codes. If done radiographically, this procedure would involve the use of codes for cannulation of a vein, the injection of contrast and the performance of a venogram. If done by ultrasound, the codes would be those for ultrasound of the artery and vein of the extremity. If a combination of both is utilized for the evaluation then an appropriate combination of codes would be warranted.
If done angiographically, then the code 36005 for cannulation and injection of contrast.  If the study is bilateral, then the code would be used a second time with the -59 modifier. There are two possible codes that could be used for the venous angiograms. The choice depends upon whether the venous mapping involves only one or both arms. The code for a single arm is 75820. If the study is bilateral then the code 75822 should be used. The code for study of the superior vena cava is 75827, if this is done.
If the study is done using ultrasound, the codes for performing ultrasound studies on the artery are 93930 and 93931. The choice of appropriate code depends on whether it is a unilateral or bilateral study. The code for a unilateral study is 93931. The code 93930 is for the bilateral study
Unless documentation is provided supporting the necessity of more than one study, one may only code either a Doppler flow study or an arteriogram, but not both.  An example of when both studies may be clinically necessary is when a Doppler flow study is performed and demonstrates reduced flow (blood flow rate less than 800cc/min or a decreased flow of 25% or greater from previous study) and the physician requires an arteriogram to further define the extent of the problem.
The codes for performing ultrasound studies on the vein are 93970 and 93971. The choice of appropriate code depends on whether it is a unilateral or bilateral study. The code for a unilateral study is – 93971. The code 93970 is for the bilateral study.
It is important to note that imaging of a vessel by only one modality can be coded at a single session. If both an ultrasound study and an angiogram are performed, only one can be coded. Since the angiographic study is the higher order study of the two, it should be the one generally chosen for assigning a code.  The only exception to this rule is as described above where the necessity for both studies performed on the artery is documented.
In summary, if the patient has had a prior access then component coding would be used. The list of codes for a unilateral study would be as follows:
Both angiography and ultrasound

93931 – Ultrasound of artery, unilateral
36005 - Cannulation of vein and injection of contrast
75820 - Venogram of single arm
75827 - Venogram of SVC (if done)

If done only by angiography then
36005 - Cannulation of vein and injection of contrast
75820 - Venogram of single arm
75827 - Venogram of SVC (if done)
Plus an arteriogram code if done

If done only by ultrasound then
93931 – Ultrasound of artery, unilateral
93971 – Ultrasound of vein, unilateral

Q We bill for access procedures and we are noticing that when billing 35476, 36147 and 75978, that Medicare is reducing us 50% for procedure code 36147.  Is this correct?  We have Medicare looking into this issue, but I wanted to check with someone there.
A Yes it is. When the bundle was negotiated the new code was made a 30000 level code. Thus, like all surgical codes is subject to the 50% reduction for multiple procedures. When the RPA negotiated the RVU for the 36147, it was 30+ percent higher the combination of 36145 and 75790. However, because the new code became a surgical code, with the 50% reduction the net is a decrease to reimbursement for us.

Q When crossing a difficult stenosis or occlusion using a directional cath with documentation would you code selectively like 36011 or just add modifier 22 to plasty code?
A The code 36011 would be appropriate only if a selective catheterization was done for an indication other than an angioplasty. If it was not needed for imaging, then it basically cannot be coded because the placement of the guidewire by whatever method used is bundled with the angioplasty code.

Q When closing a Graft for severe steal using a fogarty inflated within graft till graft thromboses. What would be appropriate code?
 A We do this from time to time, as far as I know there is no code for this. You could certainly code for a cannulation and any imaging that might be required, but as far the Fogarty catheter thrombosis, I don't know of a code that would apply.

Q We attempted a tunneled catheter removal. Did a cut down and still could not remove the catheter.  How can we bill for an unsuccessful removal even though the doctor spent over an hour on the procedure? Is there a billing code for this?
A Use the catheter removal code with a 53 modifier to indicate that the procedure was terminated.  Need to provide adequate documentation so that the carrier can make a determination.

Q We have billed the code 37186 with a 59 modifier on two different occasions to CIGNA, North Carolina’s Carrier for MCR.  We also billed 36870 as the primary procedure on both occasions.  According to the latest ASDIN guidelines for 2010, you state that you can bill this code with the modifier 59 for Embolectomy of Brachial Artery on page 21, section 2.3.3.  MCR paid the 1st one we submitted and now they are denying the second one and stating that it is an add-on code and can’t be billed with a modifier.  According to the CPT code book, 31786 is add-on code, which cannot be billed by itself and cannot be billed with a modifier.  Can you please tell me which one is correct…..ASDIN or MCR?  If MCR is incorrect, we will pursue fighting this denial with them.  We just want to make sure we have grounds to stand on when we make our appeal.  We appreciate any assistance you can give us with this matter.
A The 59 modifier while it indicates a separate procedure does not in itself apply the 50% discount. Therefore there is no conflict with viewing the 37186 as an add-on code and also using a 59 modifier. The value of the code is independent of the modifier and is based on the procedure performed as a whole. That said, the way to go is to contact the intermediary and ask them how they want you to bill it. As long as they maintain the value of the code it should not be an issue. The utilization of the code for emboli to me is what we recommend the manual, is what SIR recommends and it is what the carrier should allow.

Q If I have a 36870 that is still in the Global Period and I do a new 36870 during the global period, do I use the 79 on just the 36870 or on all the CPT codes?
A The choices of modifier to attach to the basic identifying code when a subsequent procedure is performed during the global period include 76, 77, 78 and 79. The modifier - 76 is used to indicate a repeat procedure by the same physician and modifier - 77 is use to indicate a repeat procedure performed by another physician. The terminology used in the descriptions for these codes suggest that they would be the best choice if it was apparent that the subsequent procedure was totally unrelated to the previous one. The modifier - 78 has a descriptor that suggests its use when the subsequent procedure was related to the previous one. Based upon its description, use of the modifier - 79 seems to be warranted in cases where the subsequent procedure is completely different from the previous one, neither repeated nor related.

Based upon this if you do a 36870 and then another within the global period, you should be using a 76 modifier. This is a repeat procedure performed by the same physician.
I would be very careful to state in the documentation that this is a repeat procedure but totally unrelated to the previous one. I would go on to state why this should be considered an unrelated procedure – a drop in blood pressure, etc. Documentation is always critical.  As to your question, you only need to attach the modifier to the primary procedure – in this case 36870.

Q We billed for Vein Mapping 75820 75827 36005, and 93931.  The last two codes were disallowed.  Is this correct or should we expect to be reimbursed for the injection of contrast and the ultrasound performed in association with the venogram and angiogram?
A This may be the correct set of codes for a patient who does not qualify for the G-0365 code, assuming you did each component and had proper medical indication. 36005 is the code for cannulation of a vein and injection of contrast. 75820 is the code for unilateral venography. If both arms were imaged then 75822 (bilateral) would be used instead of 75820 and a second 36005 with -59 modifier would be coded. 75827 is the code for venography of the superior vena cava. This code requires a separate medical indication such as the presence or prior use of central venous catheter. It also requires permanent image documentation of the superior vena cava
If the patient has not had a prior arteriovenous access, then the G-0365 code must be used.
If it is not allowed, it should be challenged

Q What codes would one use if tesio catheters require 4mg of alteplase to unclog two catheters 2mg of alteplase each catheter?
A This should be a single 36593 code.  The fact that it is two separate catheters with single lumens is no different than one catheter with two lumens.

Q We commonly access difficult fistulas under ultrasound at our unit before they go to dialysis, we do NOT perform a fistulogram we simply put in small catheters so that they can go for dialysis, this is performed until the unit is able to cannulate themselves.
Is there a code for such a procedure?
A No there is no code for this.

Q When billing Medicare for a central venous catheter replacement with fibrin sheath removal. We are using codes 36581(catheter exchange), 35476 (pta venous-for fibrin sheath removal), 75978 (S & I of 35476), and 77001 (fluoroscopic guidance). Medicare has been routinely denying the 77001, stating that it is included with the 35476. It will pay for 77001 only if the modifier 59 is attached. Please help clarify. Could you also address the reason why you cannot bill for a catheter removal and a catheter exchange since both are actually done.
A There is a ruling by CMS on the books for quite a while that all 70000 level codes were subject to the 59 modifier. Recently CMS has decided to enforce this which is why you are seeing a change.  36581 is a code which is specifically designed for a remove and replace through the same venous access site. It encompasses all elements of the procedure. This is discussed in detail in the coding manual and you may wish to review the chapters on catheter procedures at this time.

Q Today we brought a patient in to check if suture needed replaced on wings of perm cath.  Catheter had slipped out some so our doctor did an XR to check placement of the catheter.  Question is, since we are considered a physician office can we bill for the chest XR without doing a procedure and would we need to attach a modifier?
A Yes

Q For patients with prosthetic heart valves, what does ASDIN recommend  for prophylaxis prior to fistulogram?
A ASDIN does not have a position on this.  AHA 1990 guidelines indicate that prosthetic valves carry the highest risk for endocarditis and there are recommendations for prophylaxis with certain types of dental, gu, gi, procedures.  There are no guidelines currently available specific to fistulagram procedures.  

Q Brachial artery stuck (36120) for Fistulagram (75791) findings, Juxta-anastomotic lesion, basilic vein (mid humerus) and sucblavian lesion. 2 new cannulation sites (36148) and (36147) NOW 75791 and 36120 goes away.  Angioplasty charges are 35476 and 75798 X 2. Please just let me know if you agree with this.
A Agree

Q Can (and what if anything)  I charge for a PC flush and fresh Heparin loaded 1 a week for 1 month?
A There is no code for instilling heparin in a catheter for locking purposes.

Q Is anyone doing tunneled dialysis catheter salvage using thrombolysis?  If so, what codes are they using?
A Other than the J-code for the tPA there is no code and it may be considered part of the dialysis bundle.

Q Can we charge for more than two angioplasties if we do two in the central veins say a peripheral PTA and a PTA in the subclavian and SVC since the central two are different named vessels?
A Only 2 venous angioplasty codes are allowed in a single procedure.

Q There seemed to be some differences between the two of you on being able to charge selective catheterization of the artery.  One example that had a selective catheterization charge for the artery was clearly from the radial artery but there was also discussion that the only selective artery that could be charged is if you are in the brachial artery.  Is this just unclear or could you clarify?
A You may have confused two issues.
1. Selective catheterization of 1st and 2nd order vessels. Selective catheterization of arteries is possible (36215 and 36216).

Selective catheterization of veins has become more problematic.  36010 is bundled into 36147.  However, there is an exception to this if the SVC is accessed from a separate puncture site outside the access. 36011 and 36012 are not bundled into 36147.  However, they cannot be used for selective catheterization of the central vessels as this is explicitly defined as part of 36147.  The most common use of 36011/ 36012 would be for ligation or coiling of an accessory vessel. These codes may also be used when there is a necessity to cannulate a central vessel on the contralateral side in order to define patency or mark the vessel for stent placement.

2. Direct cannulation of arteries is where the distinction between the radial and brachial comes into play. The code for cannulation of the brachial artery is 36120. The descriptor for this code is - introduction of needle or intracatheter; retrograde brachial artery. This code is not bundled with 36147 and can therefore be used when doing procedures on dialysis vascular access. The code 36140, however, is bundled with 36147. The descriptor for this code is - introduction of needle or intracatheter; retrograde extremity artery. This is the code that you would use for the cannulation of a radial artery. 36140 cannot be used when doing procedures on dialysis vascular access.

Q I have a partner who charges an arteriogram, 75710, when he does a reflux image that sees significantly up the artery with an appropriate diagnosis.  I disagree thinking that you can only charge for arteriogram if it is done from a catheter or arterial stick.  Who is right?
A In considering the answer to this question there are several points that need to be kept in mind.
1. The artery immediately adjacent to the arterial anastomosis is considered part of the anastomosis. Therefore to warrant separate coding, the study must include more than this. The extent of artery adjacent to the anastomosis is generally stated as 2 cm; however, this is relative, it should be a significant segment of artery.
2. The code for an arteriogram is 75710, this is a radiologic code. The descriptor for this code is – angiogram, extremity, unilateral, radiological supervision and interpretation.. You are not coding for the technical aspects of the study. It doesn’t matter how the study is done technically.
3. As the manual states, you should examine that portion of the artery that is necessary to make a diagnostic evaluation related to your medical indication (Section 1.2.2 of Manual).
4. From a practical viewpoint there are only two reasons that would create a medical indication for an arteriogram – flow problems (either poor access inflow or steal) and suspicion of an arterial embolus. If the indication relates to flow, then one is generally going to need to examine all or most of the artery. This will generally require passing a catheter up the artery (I can imagine a scenario where this is not the case). Suspicion of an embolus generally only occurs in association with a thrombectomy. In this instance a reflux angiogram should not be done, it should be done via a catheter passed into the artery.
So in answer to your question, “Who is right?” In most cases you are right, but there could be an occasional case in which he is right. However, you are focusing on the wrong issue. It doesn’t really matter how the procedure is done as long as it appropriately answers the medical indication for which the study is being done.

Q Can you use 36148 for additional cannulation to do the angioplasty of the juxta-anastomotic site? Because now I need to go retrograde 36147 is for the complete procedure and my needle is antergrade.
A You would need to use 36148 for any cannulation that was for therapeutic purposes. In the example given, it appears that the access was cannulated and an angiogram was performed – this would be 36147. The second cannulation was required to treat the lesion. This would be 36148.

Q Page 64 does not tell me how you can use 75791, where was the needle already placed
Would that not be a 36147 for the complete procedure then, charge venous plasty and stent placement?
A I think that instead of page 64, you are referring to page 65 Stent Case 4. The code 75791 was used here because of the selective catheterization of the left brachiocephalic vein which was done to mark it for stent placement in the right brachiocephalic vein. The initial cannulation of the access generated the 36147; however, when the selective catheterization was performed, the cannulation component of 36147 had to be dropped. To list only the angiogram component of that code, 75791 was used. Look at Table 4 on page 11 of the Coding Manual.

Q At times, we have to do a cut-down to access the cuff, dissect, remove the catheter, and suture the cut-down site.  It there a specific billing code for this process?
A No there isn’t. This should be simply part of the catheter removal procedure with the standard code

Q I understand that ASDIN certification is needed for diagnostic interpretation but can one do ultrasound guidance for kidney transplant biopsies without certification?
A ASDIN certification is not required in order to perform or interpret renal ultrasounds including transplants or biopsy guidance but it is certainly recommended. In the future, payers may require certification.

Q I'm having problems with Palmetto GBA paying 37186 second to 36870. I was told that 37186 was only 2nd to 35470-35475 or 37205.  Please help with billing for this procedure. 
A I would refer to the coding manual and to the CPT book. The CPT book is very specific that what is recommended in the manual is correct. Not sure on what basis they can deny the claims.

Q Do PD Catheter Placement procedures need to be performed in an ASC to maximize (physician) reimbursement, as compared to an EOP (Extension of Practice), POS 11?  
A No

Q If you are doing a vein mapping and only the veins are imaged, should you attach a 52 modifier to 75820 and 75822 (for a pt that has already had a previous AVF or AVG). I know you attached it to the G codes.
A In this instance, the code is for a venous angiogram. You would not need to attach a 52 modifier if the artery is not examined since that is not part of the code to start with.



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