The Wonderful World of Interventional Radiology Coding

1. The Wonderful World of Interventional Radiology Coding Session Six The Ins & Outs of A/V Dialysis Interventions John Marshall CRA, CIRCC, RCC, RT(R), FAHRA Senior Prospective Payment Coordinator Sarasota Memorial Healthcare System

2. Disclaimer The information provided in this presentation is subject to change without notice as a result of changes in reimbursement laws, regulations, rules, policies, and payment amounts. All content in this presentation is informational only, general in nature and does not cover all situations or all payers’ rules and policies. This content is not intended to instruct hospitals and/or physicians on how to use or bill for healthcare procedures including new technologies outside of Medicare national guidelines. A determination of medical necessity is a prerequisite that is assumed to have been made prior to assigning codes or requesting payments. Hospitals and physicians should consult with appropriate payers, including Medicare fiscal intermediaries and carriers, for specific information on proper coding, billing and payment levels for healthcare procedures. This presentation represents no promise or guarantee concerning levels of reimbursement, payment, coding, billing and coverage issues. John Marshall and his wife Adrienne, specifically disclaim liability or responsibility for the results or consequences of any actions taken in reliance on anything in this presentation or the accompanying materials. Adrienne apologizes in advance for any and all embarrassing remarks that come out of John’s mouth during this presentation.

3. Coding Vascular Obstruction Procedures The Ins and Outs of A/V Dialysis Interventions

4. Hemodialysis Method of removing waste products, such as potassium and urea, and free water from the blood when the kidneys are in renal failure. • Use has 100 fold since 1972 • ~600,00 Patients Treated Per Year • Expected to reach 2,000,000 by 2030 • Costs of Vascular Access Complications $1,9000,000,00 per year

5. The Pioneers 1854 Thomas Graham 1943 Dr. Wilhelm Kolff Dr. Thomas Fogarty Dr. Julio Palmaz 5

6. Dialysis Catheters Advantages: • Same Day Dialysis Access • Alternative for Poor Fistula Candidates Disadvantages: • Prone to Infection and Clotting • Relatively Low Flow • Catheter Holes Not Self-Healing Effectiveness: 1 to 3 Months

7. Dialysis Catheters Catheter Insertion Surgical Component Insertion of non-tunneled centrally inserted venous catheter; under 5 years of age Insertion of non-tunneled centrally inserted venous catheter; age 5 years or older Insertion of tunneled centrally inserted venous catheter; under 5 years of age Insertion of tunneled centrally inserted venous catheter; age 5 years or older Insertion of tunneled centrally inserted venous access device, requiring two catheters via two separate access sites 36555 36556 36557 36558 36565

8. Dialysis Catheters Dialysis Catheters Catheter Insertion Imaging Component (RS&I) Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter (List separately in addition to code for primary procedure) Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting 77001 76937 Modifier Required

9. Dialysis Catheters Catheter Interventions Contrast injection(s) for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation and report 36598 36575 36597 36598 36581 Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous port or pump, central or peripheral insertion site Repositioning of previously placed central venous catheter under fluoroscopic guidance (Fluoro: 76000) Replacement, complete, of a non-tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access Replacement, complete, of a tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access

10. Dialysis Catheters Catheter Declotting Interventions tPa Injection Declotting by thrombolytic agent of implanted vascular access device or catheter 36593 36595 75901 36596 75902 New Access Mechanical removal of pericatheter obstructive material (eg, fibrin sheath)…via separate venous access Mechanical removal of pericatheter obstructive material (eg, fibrin sheath)… via separate venous access, RS&I Through Catheter Mechanical removal of intraluminal (intracatheter) obstructive material… through device lumen Mechanical removal of intraluminal (intracatheter) obstructive material… through device lumen, RS&I

11. Dialysis Catheters Any Easy Questions?

12. A/V Dialysis Access and Imaging

13. Arteriovenous Fistula/Grafts ArteriovenousFistula/Graft Dialysis Advantages: • Less Prone to Infection • Easy Access • High Flow Rates Disadvantages • Requires Good Vascular Site • Maintenance Required Effectiveness: 3 to 15 Years

14. Arteriovenous Fistula/Grafts ArteriovenousFistula Versus Graft Part of Body Less Infections & Clots Self Healing Med to High Clot Burden Inflow Lesions Better Initial & Post Patency Life Cost: 5 times LE$$ Matures: 1 to 4 Month Life Expectancy: >10Yr 1 Year Efficacy: 86% A/V Fistula Synthetic Graft Synthetic Implant Infection More Likely Holes Develop Low Clot Burden Outflow Lesions Less Patency Matures: 3 to 6 Weeks Life Expectancy: ~3 Yr 1 Year Efficacy: 49%

15. Arteriovenous Fistula/Grafts Typical A/V Shunt Configurations Linear Direct Loop

16. Arteriovenous Fistula/Grafts A/V Shunt Typical Structure

17. Arteriovenous Dialysis InterventionsStep By Step • Access • Angioplasty • Mechanical Thrombus Extraction • Stent Placement

18. A/V Fistula Access & Imaging Arteriovenous Dialysis Interventions 36147 + 36148 Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access of shunt, injection[s] of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava) additional access for therapeutic intervention (List separately in addition to code for primary procedure)

19. Arteriovenous Fistula/Grafts Upper Extremity Vascular Structures © J Marshall 2009

20. Arteriovenous Dialysis Interventions A/V Fistula Access & Imaging 75971 Angiography, arteriovenous shunt (eg, dialysis patient fistula/graft), complete evaluationof dialysis access, including fluoroscopy, image documentation and report (includes injections of contrast and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or vena cava) radiological supervision superior , and interpretation Only reported with an existing access

21. A/V Dialysis Access Arteriovenous Dialysis Interventions Following preparation and draping of the skin, the arteriovenous fistula was accessed using a micropuncture needle. The wire was advanced followed by a coaxial dilator system. 36147

22. A/V Dialysis Access Arteriovenous Dialysis Interventions Following preparation and draping of the skin, local anesthesia was administered. A micropuncture needle was used to access the graft. A 6 French sheath was placed. A second micropuncture needle was used to access the graft towards the arterial anastomosis.

23. Arteriovenous Dialysis Interventions A/V Dialysis Access Following preparation and draping of the skin, local anesthesia was administered. A micropuncture needle was used to access the graft. A 6 French sheath was placed. A second micropuncture needle was used to access the graft towards the arterial anastomosis. 36147 36148 Three is a crowd

24. Arteriovenous Dialysis Interventions A/V Dialysis Access There was a distal graft in the upper arm. It was accessed with a Micropuncture set. An injection was performed through the Micropuncture 4-French sheath to confirm presence of a hemodynamically significant stenosis proximally… We next positioned the catheter into the distal superior venacava and injected contrast while filming over the chest and upper arm. 36147 Access includes all imaging from access to the cava.

25. Arteriovenous Dialysis Interventions A/V Dialysis Access There was a distal graft in the upper arm. It was accessed with a Micropuncture set. An injection was performed through the Micropuncture 4-French sheath to confirm presence of a hemodynamically significant stenosis proximally. We next positioned the catheter into the distal superior venacava and injected contrast while filming over the chest and upper arm. This demonstrated the axillary, subclavian, and the innominate to be widely patent up to the level of the juncture with the superior vena cava where there was a +90% stenosis…

26. Arteriovenous Dialysis Interventions A/V Dialysis Access There was a distal graft in the upper arm. It was accessed with a Micropuncture set. An injection was performed through the Micropuncture 4-French sheath to confirm presence of a hemodynamically significant stenosis proximally. We next positioned the catheter into the distal superior venacava and injected contrast while filming over the chest and upper arm. This demonstrated the axillary, subclavian, and the innominate to be widely patent up to the level of the juncture with the superior vena cava where there was a +90% stenosis… 36147 (includes access of shunt, injection[s] of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava)

27. Imaging Beyond the A/V Fistula Arteriovenous Dialysis Interventions Cavagram Almost Always Requires Separate Access Additional Selective Imaging is Report Separately

28. Arteriovenous Dialysis Interventions Imaging Beyond the A/V Fistula … Local anesthesia was applied in the graft apex and a small skin incision was made. Graft was accessed medially towards the venous anastomosis… The graft was accessed medially towards the arterial anastomosis… Fistulagram was performed showing clot and stenosis of radial artery beyond the anastomosis. The right groin was prepped… Access was obtained with a 4-French Microstent, which was changed up to a 6-French sheath over an Amplatz stiff wire. Pigtail catheter was advanced to the Subclavian, Imaging of the upper arm was performed. Catheter was positioned in the Radial Artery … Angio was performed … 36147 36148

29. Arteriovenous Dialysis Interventions Imaging Beyond the A/V Fistula … Local anesthesia was applied in the graft apex and a small skin incision was made. Graft was accessed medially towards the venous anastomosis… The graft was accessed medially towards the arterial anastomosis… Fistulagram was performed showing clot and stenosis of radial artery beyond the anastomosis. The right groin was prepped… Access was obtained with a 4-French Microstent, which was changed up to a 6-French sheath over an Amplatz stiff wire. Pigtail catheter was advanced to the right subclavian, Imaging of the upper arm was performed. Catheter was positioned in the Radial Artery … Angio was performed … 36147 36148 Each Access Means a New Cover Charge

30. Arteriovenous Dialysis Interventions Imaging Beyond the A/V Fistula … Local anesthesia was applied in the graft apex and a small skin incision was made. Graft was accessed medially towards the venous anastomosis… The graft was accessed medially towards the arterial anastomosis… Fistulagram was performed showing clot and stenosis of radial artery beyond the anastomosis. The right groin was prepped… Access was obtained with a 4-French Microstent, which was changed up to a 6-French sheath over an Amplatz stiff wire. Pigtail catheter was advanced to the right subclavian, Imaging of the upper arm was performed. Catheter was positioned in the Radial Artery … Angio was performed … 36147 36148 36216 Each Access Means a New Cover Charge

31. Arteriovenous Dialysis Interventions Imaging Beyond the A/V Fistula … Local anesthesia was applied in the graft apex and a small skin incision was made. Graft was accessed medially towards the venous anastomosis… The graft was accessed medially towards the arterial anastomosis… Fistulagram was performed showing clot and stenosis of radial artery beyond the anastomosis. The right groin was prepped… Access was obtained with a 4-French Microstent, which was changed up to a 6-French sheath over an Amplatz stiff wire. Pigtail catheter was advanced to the right subclavian, Imaging of the upper arm was performed. Catheter was positioned in the Radial Artery … Right extremity angiogram was performed. 36147 36148 36216 36217 Highest Selective Placement Rules Supreme

32. Arteriovenous Dialysis Interventions Imaging Beyond the A/V Fistula … Local anesthesia was applied in the graft apex and a small skin incision was made. Graft was accessed medially towards the venous anastomosis… The graft was accessed medially towards the arterial anastomosis… Fistulagram was performed showing clot and stenosis of radial artery beyond the anastomosis. The right groin was prepped… Access was obtained with a 4-French Microstent, which was changed up to a 6-French sheath over an Amplatz stiff wire. Pigtail catheter was advanced to the right subclavian, Imaging of the upper arm was performed. Catheter was positioned in the Radial Artery … Right extremity angiogram was performed. 36147 36148 36216 36217 75710 Don’t forget the RS&I code.

33. Arteriovenous Dialysis Interventions A/V Dialysis Interventions

34. Arteriovenous Dialysis Interventions No Sir.org!

35. Arteriovenous Dialysis Interventions

36. Arteriovenous Dialysis Interventions A/V Angioplasty

37. Arteriovenous Dialysis Interventions A/V Angioplasty Angioplasty Reported Per Vessel Arterial Anastomosis Through Axillary is One Vessel Surgical and RS&I Codes Reported for Each Angioplasty Access & Diagnostic Imaging Reported Separately Venous Angioplasty Reported Beyond Shunt Arterial Plasty Must Be Substantially Away From the Anastomosis (juxta-anastomosis stenosis)

38. Arteriovenous Dialysis Interventions A/V Angioplasty Surgical Component CMS Abolished Unique HCPCS

39. Arteriovenous Dialysis Interventions A/V Angioplasty Surgical Component

40. Arteriovenous Dialysis Interventions A/V Angioplasty Imaging Component

41. A/V Angioplasty Coding Arteriovenous Dialysis Interventions There is a moderate stenosis in the mid-fistula. An 8 mm by 4 cm balloon was advanced over a guidewire and the lesion was dilated to two atmospheres. Post inflation images show a 30% restenosis. The balloon was reinserted and dilated to four atmospheres. Significant improvement can be seen following the dilatations with some residual spasm. 36147

42. A/V Angioplasty Coding Arteriovenous Dialysis Interventions There is a moderate stenosis in the mid-fistula. An 8 mm by 4 cm balloon was advanced over a guidewire and the lesion was dilated to two atmospheres. Post inflation images show a 30% restenosis. The balloon was reinserted and dilated to four atmospheres. Significant improvement can be seen following the dilatations with some residual spasm. 36147 35476 75978

43. Arteriovenous Dialysis Interventions How Many Angioplasties? 36147 Multiple injections were made demonstrating a moderate stenosis at the cephalic anastomosis and a moderate severe stenosis in the axillary vein. At the cephalic anastomosis an 8 mm balloon was used. Following dilatation, significant improvement is seen. However, some narrowing is still seen. After several attempts, using a curved catheter, a glidewire was used to transverse the axillary stenosis and an 8 mm balloon was used. Following dilatation, a significant improvement is seen. One Two

44. Arteriovenous Dialysis Interventions ONE Angioplasty 36147 Multiple injections were made demonstrating a moderate stenosis at the cephalic anastomosis and a moderate severe stenosis in the axillary vein. At the cephalic anastomosis an 8 mm balloon was used. Following dilatation, significant improvement is seen. However, some narrowing is still seen. After several attempts, using a curved catheter, a glidewire was used to transverse the axillary stenosis and an 8 mm balloon was used. Following dilatation, a significant improvement is seen. 35476 75978 Graft Zone: Arterial Anastomosis through the Axillary

45. Arteriovenous Dialysis Interventions Mechanical Thrombectomy

46. Includes All Mechanical Methods: All Thrombectomy Removal Procedures Fogarty Balloon Pharmalogical “Lyse and Wait” Snare Catheters Cutting Balloons Access/Imaging and Other Percutaneous Interventions are separately reportable. Arteriovenous Dialysis Interventions Mechanical Thrombectomy

47. Arteriovenous Dialysis Interventions Mechanical Thrombectomy A/V Thrombectomy is Reported Once, Regardless of Number of Methods Used Subsequent or Prior Continuous Infusion of a Thrombolytic is Reported Separately. Thrombectomy Outside the Graft Zone Reported as Percutaneous Thrombectomy or Thrombolysis

48. Arteriovenous Dialysis Interventions Mechanical Thrombectomy Occlusion of the upper arm AV graft was apparent. A 60 cm Xpeedior thrombectomy catheter was advanced and operated over the 0.035" wire through the graft and into the central circulation. Multiple passes with the device resulted in clearance of a large amount of thrombus from the graft and central vein. The graft was punctured near the venous anastomosis and a sheath was directed toward the arterial anastomosis. A 5.5Fr Fogarty® balloon was passed into the arterial anastomosis and the arterial plug was pulled into the central circulation.

49. Arteriovenous Dialysis Interventions Mechanical Thrombectomy Occlusion of the upper arm AV graft was apparent. A 60 cm Xpeedior thrombectomy catheter was advanced and operated over the 0.035" wire through the graft and into the central circulation. Multiple passes with the device resulted in clearance of a large amount of thrombus from the graft and central vein. The graft was punctured near the venous anastomosis and a sheath was directed toward the arterial anastomosis. A 5.5Fr Fogarty® balloon was passed into the arterial anastomosis and the arterial plug was pulled into the central circulation. 36147 36870 36148 ? Two separate accesses.

50. Arteriovenous Dialysis Interventions Mechanical Thrombectomy Occlusion of the upper arm AV graft was apparent. A 60 cm Xpeedior thrombectomy catheter was advanced and operated over the 0.035" wire through the graft and into the central circulation. Multiple passes with the device resulted in clearance of a large amount of thrombus from the graft and central vein. The graft was punctured near the venous anastomosis and a sheath was directed toward the arterial anastomosis. A 5.5Fr Fogarty® balloon was passed into the arterial anastomosis and the arterial plug was pulled into the central circulation. 36147 36870 36148 By any means necessary!