Heart of the Matter: Actionable Coding Strategies for Vascular Access and Interventions

Of all the coding areas to approach with caution, cardiology coding remains in the top tier. Cardiology CPT^® coding is notoriously complex due to the intricate nature of cardiovascular procedures and the frequent updates to coding guidelines. Unlike many other specialties, cardiology encompasses a wide range of diagnostic and interventional procedures, including cardiac catheterization, electrophysiology studies, echocardiography, and coronary interventions like angioplasty and stenting. Each procedure could involve multiple components—such as imaging, supervision, and interventional techniques—that must be accurately reported. Interventional radiology plays a crucial role in managing arteriovenous (AV) fistulas and grafts for dialysis patients, ensuring proper blood flow and functionality. Understanding the differences between AV fistulas and grafts, as well as the coding nuances for diagnostic and interventional procedures, is essential for accurate medical billing and compliance. Let’s analyze the nuances for actionable answers to create success in 2025 and beyond.

Analyzing Vascular Access and the Dialysis Circuit Fundamentals

For patients undergoing long-term dialysis, maintaining a reliable vascular access point is essential. This is typically achieved through an arteriovenous (AV) fistula or an AV graft—two distinct but sometimes confused methods. An AV fistula is created by directly connecting a patient’s vein to an artery, promoting natural blood flow and vessel maturation. In contrast, an AV graft involves the use of an artificial tube that bridges a vein and an artery, providing an alternative when a fistula is not feasible. While the arm is the most common location for both, veins and arteries in the thigh may be used if necessary. These access points, often referred to as shunts, serve as the lifeline for dialysis patients, ensuring efficient blood filtration.

When it comes to diagnostic and interventional procedures, understanding the structure of the dialysis circuit is crucial. The circuit extends from the arterial connection (arterial anastomosis) to the heart’s right atrium and consists of two key segments: the peripheral and central dialysis segments. The peripheral segment stretches from the arterial anastomosis through the axillary or cephalic vein, while the central dialysis segment includes the subclavian and innominate veins leading to the superior vena cava. Understanding hierarchies is a critical step to accurate coding. Coding for procedures within the dialysis circuit follows a specific hierarchy under CPT codes 36901–36909, which cover everything from diagnostic imaging to angioplasty, stenting, and embolization. Unlike standard vascular interventions, these codes are tailored specifically for dialysis-related procedures, ensuring precise reporting and compliance.

36901  Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report;

36902  Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report; with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty

36903  Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report; with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis segment

36904  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);

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

36906  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 transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis circuit

+36907  Transluminal balloon angioplasty, central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and interpretation required to   perform the angioplasty (List separately in addition to code for primary procedure)

+36908 Transcatheter placement of intravascular stent(s), central dialysis segment, performed   through dialysis circuit, including all imaging and radiological supervision and interpretation required to perform the stenting, and all angioplasty in the central dialysis segment (List separately in addition to code for primary procedure)

+36909 Dialysis circuit permanent vascular embolization or occlusion (including main circuit or any accessory veins), endovascular, including all imaging and radiological supervision and interpretation necessary to complete the intervention (List separately in addition to code for primary procedure)

Actionable Coding Tips to Drive Success in 2025

• If performing interventional procedures in addition to diagnostic angiography, it may be appropriate to charge separately for each portion of the study. See the CPT Manual for guidelines associated with each code to determine when diagnostic angiography may be separately coded.
• Also, please refer to the following link for the most current information pertaining to CCI instructions relative to this topic: https://www.cms.gov/medicare-medicaid-coordination/national-correct-coding-initiative-ncci/ncci-medicare/ncci-medicare-policy-manual
• Code 36901: Use for diagnostic imaging of the dialysis circuit without therapeutic intervention. Do not report with codes 36902–36906, but code 36901 may be used with add-on codes 36907–36909.
• Single access: 36901 covers one or more accesses and includes catheterization, imaging of the entire dialysis circuit, and venous side branches.
• Modifier 52: Use with 36901 in the professional setting if only a fistulagram is performed via an existing access.
• Angioplasty: If performed in the peripheral segment, report 36902. If performed in the central segment, see add-on code 36907. Angioplasty is included in codes 36903-36906, therefore when angioplasty is performed in the same segment as the procedures described by these codes it is not separately reported.
• Stents and Thrombectomy:
  • Use 36903 for stent placement in the peripheral segment.
  • Use 36904 for stent mechanical thrombectomy/thrombolysis.
  • Use 36905 if angioplasty is performed with thrombectomy/thrombolysis in the peripheral segment.
  • Use 36906 for stent placement with thrombectomy in the peripheral segment.

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 As part of Heart Month, check out Heart Failure Coding Essentials: Ensuring Compliance and Optimal Reimbursement on February 26, 2025,  at 12:30 pm CT.

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