Learn the difference between CPT Code 36147 vs 36148, 75791 for correct coding of Arteriovenous (AV) Fistula/Shunt/Graft.
An arteriovenous fistula is an abnormal connection or passageway between an artery and a vein. It may be congenital, surgically created for hemodialysis treatments, or acquired due to pathologic process, such as trauma or erosion of an arterial aneurysm.
While if we take a look at Arteriovenous (AV) Shunt definition according to CPT guidelines:
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. An AVG also involves creating openings in an artery and a vein, but uses an artificial vessel to link the two openings
CPT can pack a lot into one little code. Let's take a closer look at Arteriovenous (AV) Fistula/ Shunt/ Graft coding with using CPT codes 36147, 36148 and/or 75791:
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).
When CPT Code 36147 is Used
CPT Code 36147 is reported when the physician performs a fistulagram to evaluate a dialysis arteriovenous fistula or graft. This code includes all components of the fistulagram, including the work of the initial puncture into the graft or fistula and all of the necessary imaging from the arterial anastomosis through the entire venous outflow – including the central veins and superior or inferior vena cava. This code also includes all of the catheter manipulation to perform the diagnostic examination, including advancement of the catheter to the cava if necessary to fully visualize the central veins.
Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); additional access for therapeutic intervention (list separately in addition to code for primary procedure).
When CPT Code 36148 is Used
CPT Code 36148 was established to describe the placement of a second (additional) access that may be necessary to perform a therapeutic procedure (e.g., percutaneous transluminal angioplasty, thrombolysis). Please note that code 36148 is an add-on code that is reported only in conjunction with code 36147.
Angiography, arteriovenous shunt (eg, 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.
When CPT Code 75791 is Billed
CPT Code 75791 is reported to describe the imaging of the arteriovenous dialysis fistula or graft performed through an existing access (e.g., patient presents from the dialysis suite with needles placed into the graft or fistula, or from a remote access such as the femoral artery that is not a direct puncture to the graft, or images from an operative angiogram that are submitted for interpretation only). The imaging includes the entire length of the graft or fistula and all of the outflow veins through the central veins, including the vena cava.
When procedure codes 36147 and 75791 are used to report the services described in this LCD (appropriate evaluation of the patency of an established hemodialysis fistula and the percutaneous interventions needed to enhance or re-establish patency of that hemodialysis fistula), the following diagnosis codes will be considered by Medicare to support medical necessity:
A medical coder should 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.
CPT Code 36148 is not used 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).
An arteriovenous fistula is an abnormal connection or passageway between an artery and a vein. It may be congenital, surgically created for hemodialysis treatments, or acquired due to pathologic process, such as trauma or erosion of an arterial aneurysm.
While if we take a look at Arteriovenous (AV) Shunt definition according to CPT guidelines:
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).
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. An AVG also involves creating openings in an artery and a vein, but uses an artificial vessel to link the two openings
Arteriovenous (AV) Fistula, Shunt, Graft: 36147 vs 36148 vs 75791
Medical Coders typically use CPT 36147 for patients with end-stage renal disease (ESRD), having trouble with his AV shunt for dialysis and requires an evaluation.CPT can pack a lot into one little code. Let's take a closer look at Arteriovenous (AV) Fistula/ Shunt/ Graft coding with using CPT codes 36147, 36148 and/or 75791:
36147 Access AV Dial Grft for Eval
CPT Code 36147 DescriptionIntroduction 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).
When CPT Code 36147 is Used
CPT Code 36147 is reported when the physician performs a fistulagram to evaluate a dialysis arteriovenous fistula or graft. This code includes all components of the fistulagram, including the work of the initial puncture into the graft or fistula and all of the necessary imaging from the arterial anastomosis through the entire venous outflow – including the central veins and superior or inferior vena cava. This code also includes all of the catheter manipulation to perform the diagnostic examination, including advancement of the catheter to the cava if necessary to fully visualize the central veins.
36148 Access AV Dial Grft for Proc
CPT Code 36148 DescriptionIntroduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); additional access for therapeutic intervention (list separately in addition to code for primary procedure).
When CPT Code 36148 is Used
CPT Code 36148 was established to describe the placement of a second (additional) access that may be necessary to perform a therapeutic procedure (e.g., percutaneous transluminal angioplasty, thrombolysis). Please note that code 36148 is an add-on code that is reported only in conjunction with code 36147.
75791 AV Dialysis Shunt Imaging
CPT Code 75791 DescriptionAngiography, arteriovenous shunt (eg, 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.
When CPT Code 75791 is Billed
CPT Code 75791 is reported to describe the imaging of the arteriovenous dialysis fistula or graft performed through an existing access (e.g., patient presents from the dialysis suite with needles placed into the graft or fistula, or from a remote access such as the femoral artery that is not a direct puncture to the graft, or images from an operative angiogram that are submitted for interpretation only). The imaging includes the entire length of the graft or fistula and all of the outflow veins through the central veins, including the vena cava.
When procedure codes 36147 and 75791 are used to report the services described in this LCD (appropriate evaluation of the patency of an established hemodialysis fistula and the percutaneous interventions needed to enhance or re-establish patency of that hemodialysis fistula), the following diagnosis codes will be considered by Medicare to support medical necessity:
| Code | ICD code description |
|---|---|
| 440.31 | ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT OF THE EXTREMITIES |
| 440.32 | ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT OF THE EXTREMITIES |
| 442.0 | ANEURYSM OF ARTERY OF UPPER EXTREMITY |
| 442.3 | ANEURYSM OF ARTERY OF LOWER EXTREMITY |
| 444.21 | ARTERIAL EMBOLISM AND THROMBOSIS OF UPPER EXTREMITY |
| 444.22 | ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY |
| 447.0 | ARTERIOVENOUS FISTULA ACQUIRED |
| 447.1 | STRICTURE OF ARTERY |
| 451.82 | PHLEBITIS AND THROMBOPHLEBOTIS OF SUPERFICIAL VEINS OF UPPER EXTREMITIES |
| 453.40 | ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY |
| 453.41 | ACUTE VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF PROXIMAL LOWER EXTREMITY |
| 453.42 | ACUTE VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF DISTAL LOWER EXTREMITY |
| 453.50 | CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY |
| 453.51 | CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF PROXIMAL LOWER EXTREMITY |
| 453.52 | CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF DISTAL LOWER EXTREMITY |
| 453.6 | VENOUS EMBOLISM AND THROMBOSIS OF SUPERFICIAL VESSELS OF LOWER EXTREMITY |
| 453.71 | CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF SUPERFICIAL VEINS OF UPPER EXTREMITY |
| 453.72 | CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF DEEP VEINS OF UPPER EXTREMITY |
| 453.73 | CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF UPPER EXTREMITY, UNSPECIFIED |
| 453.74 | CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF AXILLARY VEINS |
| 453.75 | CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF SUBCLAVIAN VEINS |
| 453.76 | CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF INTERNAL JUGULAR VEINS |
| 453.77 | CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF OTHER THORACIC VEINS |
| 453.79 | CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF OTHER SPECIFIED VEINS |
| 453.81 | ACUTE VENOUS EMBOLISM AND THROMBOSIS OF SUPERFICIAL VEINS OF UPPER EXTREMITY |
| 453.82 | ACUTE VENOUS EMBOLISM AND THROMBOSIS OF DEEP VEINS OF UPPER EXTREMITY |
| 453.83 | ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UPPER EXTREMITY, UNSPECIFIED |
| 453.84 | ACUTE VENOUS EMBOLISM AND THROMBOSIS OF AXILLARY VEINS |
| 453.85 | ACUTE VENOUS EMBOLISM AND THROMBOSIS OF SUBCLAVIAN VEINS |
| 453.86 | ACUTE VENOUS EMBOLISM AND THROMBOSIS OF INTERNAL JUGULAR VEINS |
| 453.87 | ACUTE VENOUS EMBOLISM AND THROMBOSIS OF OTHER THORACIC VEINS |
| 453.89 | ACUTE VENOUS EMBOLISM AND THROMBOSIS OF OTHER SPECIFIED VEINS |
| 459.2 | COMPRESSION OF VEIN |
| 996.1 | MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT |
| 996.62 | INFECTION AND INFLAMMATORY REACTION DUE TO OTHER VASCULAR DEVICE IMPLANT AND GRAFT |
| 996.73 | OTHER COMPLICATIONS DUE TO RENAL DIALYSIS DEVICE IMPLANT AND GRAFT |
| 996.74 | OTHER COMPLICATIONS DUE TO OTHER VASCULAR DEVICE IMPLANT AND GRAFT |
A medical coder should 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.
CPT Code 36148 is not used 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).
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