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Percutaneous Transluminal Angioplasty

January 25, 2017
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Question:

If PTA of the venous and arterial anastomosis are performed, do we code for both a venous PTA (35476) and an arterial PTA (35475), or just one?

Answer:

It’s important to note that coding for these procedures will change effective January 1, 2017.  So, if you’re looking at claims prior to January 1, 2017, the April 2012 AMA CPT® Assistant notes, “Angioplasty and stenting are coded only once for the entire AV dialysis access “vessel”, which is defined for coding purposes as extending from the arterial anastomosis through the axillary vein in arm accesses and from the arterial anastomosis through the common femoral vein in leg accesses. Even if multiple separate stenoses are treated in this segment, the angioplasty and stenting codes should be reported only once. If arterial codes are used to report an intervention at the arterial anastomosis, venous codes should not be reported for the treatment of lesions distal to the arterial anastomosis but within the dialysis access vessel.”

For coding angioplasty of the AV dialysis circuit, the entire graft from the arterial anastomosis through the venous anastomosis, as well as the outflow vein, up to but not including the subclavian vein, is considered a single vessel. All interventions performed within this area would be reported only once. The majority of the time, this is a venous angioplasty code and would be reported using 35476 and 75978. However, if the stenosis in the AV graft that is treated is at the arterial anastomosis, it may be coded with arterial angioplasty codes 35475 and 75962. This code would then apply to all other stenoses treated within the AV dialysis circuit. Therefore, all angioplasty within the AV dialysis circuit would be coded with either 35475 and 75962, or 35476 and 75978. The appropriate code is chosen dependent upon whether a true arterial anastomotic stenosis is treated. If a stenosis outside the defined graft vessel is treated, either arterial or venous, a separate angioplasty code may be assigned, along with the appropriate modifier assignment to clarify that separate vessels were treated. The clinical indication for treatment of these lesions should be clearly documented in the medical record.

Effective January 1, 2017, the entire region described in the separate, clinical documentation you provided would be classified as the peripheral dialysis segment, which is defined in the CPT book as being the portion of the dialysis circuit that begins at the arterial anastomosis and extends to the central dialysis segment. Therefore, the procedure would be coded using a single CPT code of 36905, which includes the mechanical thrombectomy and angioplasty of the entire peripheral dialysis segment, in addition to the direct access and all imaging necessary to complete the procedure.
The codes and their descriptions are noted below:

35476 (Transluminal balloon angioplasty, percutaneous; venous)

75978 (Transluminal balloon angioplasty, venous (eg, subclavian stenosis), radiological supervision and interpretation)

35475 (Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel)

75962 (Transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation)

36905  (Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s); with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty)

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