Super coding tips for 36147 AV fistula or Shunt or Graft

36147 AV fistula or Shunt or Graft
Radiocephalic fistula (Photo credit: Wikipedia)

CPT code 75791, 36147 and 36148, all three codes are deleted in 2017. To report AV fistula exam procedures, now we have new CPT codes introduced in 2017. Hence, from 2017 instead of using 36147, 36148 and 75791, we have to report below CPT codes.

CPT code 36901, 36902, 36903, 36904, 36905, 36906 .

You can get all the code description in the below blog post.

New CPT codes changes of 2017

AV Shunt: 36147: Get a Better Picture of Fistula vs. Graft
Get the official word on what makes 75791 different from 36147.
CPT can pack a lot into one little code. Here's a closer look at just what "arteriovenous shunt created for dialysis [graft/fistula]" means in 36147.
The code: The code in focus here and in "36147 Features Official Includes/Excludes Rules in 2012," on page 27, is 36147 (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]). Earlier we have learn complicated procedure about coding removal of foreign body and Bone marrow aspiration with biopsy coding, now we have one more complicated procedure to learn i.e. AV fistula coding. These tips are really important for Certification exams like CPC, you can go through sample CPC questions here which is surely help in clearing CPC exam.

CPC Practice Exam - Medical Coding Study Guide Please Click Here!



You'll typically use 36147 when a patient with end-stage renal disease (ESRD) is having trouble with his AV shunt for dialysis and requires an evaluation.
AV shunt defined: "For diagnostic studies, the arteriovenous (AV) dialysis shunt (AV shunt) is defined as beginning with the arterial anastomosis [opening between two normally separate structures] and extending to the right atrium. This definition includes all upper and lower extremity AV shunts (arteriovenous fistulae [AVF] and arteriovenous grafts [AVG])," CPT guidelines state.
An AVF for dialysis is surgically created by cutting an opening in an artery and an opening in a nearby vein and then joining the openings together so that blood can communicate between the artery and the vein (see Figure 1). An AVG also involves creating openings in an artery and a vein, but uses an artificial vessel to link the two openings (see Figure 2).
Contrast with +36148, 75791: CPT Assistant (March 2010) reminds you that you have two additional codes to consider for AV shunt services. Report +36148 (...additional access for therapeutic intervention [List separately in addition to code for primary procedure]) in addition to 36147 if the initial evaluation (36147) prompts a therapeutic intervention requiring a second shunt catheterization.
Remember that you don't use +36148 to identify a second diagnostic injection procedure from a second access point. Use +36148 when an interventional procedure is provided from that second access point.
If percutaneous access had already been established prior to the service, 36147 would not be appropriate. You should instead report 75791 (Angiography, arteriovenous shunt [e.g., dialysis patient fistula/graft], complete evaluation of 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 superior vena cava], radiological supervision and interpretation)


You still shouldn't be too hasty in adding the US code to your claim.
A recent Correct Coding Initiative (CCI) edit deletion simplifies reporting ultrasound guidance with arteriovenous (AV) shunt access.
Effective April 1, 2012, for physicians, CCI deleted the edit bundling these two codes, according to Frank Cohen, principal and senior analyst for The Frank Cohen Group, in his NCCI Change Analysis 18.1:
36147, 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)
+76937, 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).
The edit had a modifier indicator of 1, meaning that you could override it with a modifier, such as 59 (Distinct procedural service), when appropriate. The edit deletion means you should no longer need to append a modifier for payers to reimburse both codes.
Caution: Before adding +76937 to your 36147 claim, review whether documentation truly supports reporting ultrasound guidance. As CPT guidelines explain, "Particularly in the case of new or failing AVF [AV fistula], ultrasound may be necessary to safely and effectively puncture the AV access for evaluation, and this may be reported separately with 76937 if all the appropriate elements for reporting 76937 are performed."
In other words, the physician should document the medical necessity for using the ultrasound guidance in the patient's specific case. CPT guidelines for ultrasound guidance also "require permanently recorded images of the site to be localized, as well as a documented description of the localization process, either separately or within the report of the procedure for which the guidance is utilized."


You Be the Coder: Factor in More than Fistula Imaging
Question: The radiologist punctured the right forearm fistula and performed imaging of the upper arm, axillary, subclavian, and SVC. He also did a right radial artery puncture and radial artery arteriogram was done under ultrasound guidance. There is no documentation of a permanent image for the US guide. How do I report the artery puncture and imaging for the right radial artery?

Answer: For the right radial artery puncture and radial artery arteriogram, look at 36140-59 (Introduction of needle or intracatheter; extremity artery; Distinct procedural service) and 75710 (Angiography, extremity, unilateral, radiological supervision and interpretation). Append modifier 26 to 75710 if you’re reporting only the professional component.

You should append modifier 59 to 36140 to indicate it’s a separate puncture from the one required for the fistula puncture and imaging. The fistula service, including imaging through the superior vena cava (SVC), is reported using 36147 (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]).
Rationale: Even assuming the right radial artery is the inflow vessel of the fistula, the separate puncture and imaging should be separately reportable if you have supporting documentation. CPT guidelines state: “The arterial inflow to the AV access is considered a separate vessel. If a more proximal inflow problem separate from the peri-anastomotic segment is suspected and additional catheter work and imaging must be done for adequate evaluation, this work is not included in 36147.”

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