Dialysis Shunt Maintenance (DL32009)

Contractor Information

Contractor Name
Wisconsin Physicians Service Insurance Corporation		 Contractor Number
00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402		 Contractor Type
Carrier - FI - MAC

LCD Information

Document Information
Draft stamp
LCD ID Number
DL32009

LCD Title
Dialysis Shunt Maintenance

Contractor's Determination Number
CV-027

AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction


Oversight Region


Original Determination Effective Date


Original Determination Ending Date


Revision Effective Date


Revision Ending Date


CMS National Coverage Policy
Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Publications:
CMS Internet Only Manuals

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 11: End Stage Renal Disease (ESRD):
20.1 Noninvasive Vascular Studies for End Stage Renal Disease (ESRD) Patients
30.4.2 Separately Billable Drugs.
30.5 ESRD Composite Payment Rates
80 Physician's Services for Renal Dialysis Patients General
80.1 - Physicians' Services to an ESRD Inpatient
80.2 - Physicians' Services - Outpatient Maintenance Dialysis

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 14: Medical Devices:
10 Coverage of Medical Devices
20 FDA Approval Investigational Device Exemptions
(IDEs) 20.2 - Category B

Medicare Claims Processing Manual
Chapter 8 - Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims
140 - Monthly Capitation Payment Method for Physicians' Services Furnished to Patients on Maintenance Dialysis; (Rev. 1456, Issued: 02-22-08, Effective: 03-24-08, Implementation: 03-24-08)
180 - Noninvasive Studies for ESRD Patients - Facility and Physician Services
(Rev. 1, 10-01-03) AB-01-189, AB-03-001

CMS Publication 100-03, Medicare National Coverage Determinations Manual, Part 1:
20.7.B1 Percutaneous Transluminal Angioplasty (PTA)
20.7.D Other

CMS Publication 100-09, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5: Correct Coding Initiative.

Program Memorandum: AB-00-44; AB-00-55; B-01-28; AB-01-129; AB-01-129.1
CMS Transmittal AB-00-44, Change Request #1118, May 2000: Medicare Coverage of Non-Invasive Vascular Studies When Used to Monitor the Access Site of End Stage Renal Disease (ESRD) Patients.
CMS Transmittal AB-00-55, Change Request #1117, June 2000: Hemodialysis Flow Study.

Formerly:
Medicare Carriers Manual: 2230-2230.5, 2231.4; 4272-4275.2; 15060.1
Coverage Issue Manual, Section 50-32 allows coverage for a (PTA) of arterio-venous dialysis fistulae and grafts.
Indications and Limitations of Coverage and/or Medical Necessity
LCD Description

Arteriovenous (AV) dialysis access (AV fistula, AV dialysis graft) interventions are intended to restore and/or maintain functional patency of the AV dialysis access. These procedures encompass a number of percutaneous or open surgical procedures. Indications for interventions on an AV dialysis access include compromised flow with threatened occlusion, recent thrombosis of AV dialysis access, and management of structural abnormalities such as pseudoaneurysms. Interventions are performed on AV dialysis fistulas and grafts in order to restore adequate flow, to preserve the access' function, and avoid the need to create a new AV access. Fistulae which are not maturing as expected are also evaluated and treated with percutaneous interventions.

Percutaneous interventions to enhance or re-establish patency of a hemodialysis AV access have proven useful in extending the life of the access, reducing the need for open repair, reconstruction or replacement. The longevity and quality of life of the end stage renal dialysis (ESRD) patient are improved.

Definitions:

(AV) dialysis access: A surgically-created communication between an artery and a vein used for vascular access for hemodialysis. The communication may be a direct fistula (AV fistula) (e.g. Brescia Cimino fistula), brachiocephalic fistula or an interposed conduit (AV graft) (e.g. brachiocephalic loop graft). The conduit may be an autogenous vessel or synthetic material.

Percutaneous transluminal angioplasty (PTA): An invasive procedure which, when successful, enlarges a narrowed vascular lumen. Typically, a balloon-tipped catheter is introduced percutaneously into the narrowed vessel. The balloon is inflated at the site of vascular stenosis, stretching the vessel and opening the lumen to restore adequate flow through the vessel. The balloon is removed after angioplasty.

Thrombolysis: Pharmacologic and/or mechanical dissolution of a thrombus or blood clot.

Infusion: Continuous intravenous administration of a medication containing solution lasting longer than thirty (30) minutes. Bolus injections are not considered infusions, regardless of the time required to inject the solution.

Shunt: An arteriovenous conduit

Embolization/ligation of collateral branch veins: AV fistulae depend on a single outflow vein to carry the flow, so that this vein can enlarge to the point it is easily punctured and has brisk flow. If branch veins are large enough to siphon off a significant amount of flow, no single vein will enlarge enough to be used. Closing off the side branches may allow the outflow vein to mature. The side branches may be closed off surgically by tying off the branches, or may be closed off by placement of occlusive material into the side branch through a catheter (embolization).



Interventions:
Percutaneous interventions to enhance or re-establish patency of a hemodialysis AV fistula have proven useful in extending the life of the fistula, reducing the need for open repair, reconstruction or replacement. The longevity and quality of life of the ESRD patient are positively impacted
Percutaneous AV fistula declotting, maintenance or re-establishment of appropriate and adequate flow may encompass the following procedures:
- Access by introduction of either needle or vascular sheath into the AV shunt (e.g., 36145)
- Mechanical and/or pharmacologic maneuvers to promote dissolution, fragmentation, and/or removal of obstructing thrombotic materials e.g., 36860, 36861).

PTA may be necessary if, after removal of thrombotic material, flow remains inadequate and examination and/or angiography demonstrates residual, hemodynamically significant, impediment to flow that is caused by other than thrombotic material. Residual hemodynamically significant flow impairment may be demonstrated within the AV fistula, at either anastomotic junction or more remotely in the artery or vein providing the fistula's inflow and outflow (e.g., 35475, 35476).
Therapeutically directed angiography (e.g., 75710, 75790). These need not all be performed on every dysfunctional shunt. Each may, under unique circumstances, be considered reasonable and medically necessary

Open surgical therapy for thrombosed dialysis cannulae or hemodynamically significant flow impediment utilizes direct access to the conduit and contiguous vessels. Mechanical fragmentation and surgical removal of occlusive thrombotic material is effected under direct visualization. Adjunctive thrombolytic pharmacotherapy may be employed. Residual vascular stenoses or obstructive lesions are removed and corrected using standard vascular surgical techniques (e.g., 36832, 36834). Angiography is adjunctively employed, when appropriate and medically necessary, to assess the functional integrity of afferent and efferent vessels remote from the surgical field

Indications and Limitations of Coverage and/or Medical Necessity

Evaluation of shunt function:

Typically, the clinical examination provides adequate information to determine whether there is hemodynamically significant dialysis shunt dysfunction. The following clinical findings are considered diagnostically specific and appropriate indications to initiate therapies to re-establish physiologically appropriate flow in the dialysis fistula

1. Venous outflow impediment:
a. Elevated venous pressure in the graft
b. Elevated venous/arterial ratio (static venous pressure ratio - above 40%)
c. Prolonged bleeding following needle removal
d. Inefficient dialysis
e. Recirculation percentage greater than 10-15%
f. Development of pseudoaneurysms
g. Swelling of the extremity
h. Large collateral venous channels
i. Loss of "machine-like" bruit, i.e., short sharp bruit
j. Abnormal physical findings, specifically pulsatile graft or loss of thrill

2. Arterial inflow impediment:
a. Low pressure in graft even when outflow is manually occluded
b. Ischemic changes of the extremity (steal syndrome)
c. Diminished intra-access flow

Evaluation of Dialysis Access Dysfunction Diagnostic Tests

If a stenosis is suspected clinically, typically a diagnostic study is required to determine the level(s) of disease and to formulate a plan for treatment. This is most commonly accomplished with a fistulagram (CPT code 36147).
Diagnostic fistulagram with puncture of the AV dialysis access with needle or catheter placement, and diagnostic angiography of the entire AV dialysis access circuit, from the arterial anastomosis through the central veins and cava, which is performed to identify the area or areas of narrowing or occlusion that are creating flow problems for the AV dialysis access (CPT code 36147). This includes visualization and examination of the vena cava.
Diagnostic fistulagram without directly puncturing and/or catheterizing the AV dialysis access.
For instance, a fistulagram may be performed through an existing needle or sheath or via an injection of a vessel other than direct puncture of the AV dialysis access (e.g., injection of the subclavian artery through a femoral arterial puncture) (CPT code 75791).

Diagnostic non-invasive vascular studies (CPT code 93990) performed to evaluate an AV access are reasonable and necessary in the presence of signs and symptoms of impending failure of the access sites and when the result may impact the clinical course of the patient. -Additional duplex studies of this area are not covered in addition to this code. For more information see the policy on non-invasive vascular testing.


The consistent monitoring of dialysis access is an essential element in the quality of care provided to the patient on dialysis. This routine evaluation and monitoring is considered valuable but is included in the composite rate paid to the dialysis facility by Part A and or the monthly capitation payment paid to the physician.

Treatment of shunt malfunction

Percutaneous AV Dialysis Access Maintenance and Salvage

Percutaneous AV dialysis access declotting, maintenance, or re-establishment of appropriate and adequate flow may encompass any of the procedures listed below. These need not all be performed on every dysfunctional access, but each may, under unique circumstances, be considered reasonable and medically necessary.
1. Mechanical and/or pharmacologic maneuvers to promote dissolution, fragmentation and/or removal of obstructing thrombotic materials (CPT code 36870) - includes all work necessary to remove thrombus from the AV dialysis access, including mechanical thrombolysis, mechanical removal of thrombus, as well as all pharmacological means of removing thrombus from the dialysis access (including bolus, infusion, pulse-spray etc.).

2. PTA of the dialysis conduit and/or afferent and efferent vessels is not necessary for all shunt dysfunction situations. Coverage will be considered if there is documentation supporting the presence of residual, hemodynamically significant flow restriction after any previous interventions. There must be clear documentation of the site and extent of any hemodynamically significant, stenosis. This documentation may be subjected to medical necessity review.

3. Venous PTA PTA is typically necessary to treat stenoses. The stenosis is most commonly found at the level of the venous anastomosis for synthetic graft accesses, but can be found anywhere from the arterial inflow through the vena cava. Multiple stenoses are found in a significant percentage of patients. When the patient presents with a thrombosed AV access, PTA is commonly needed after the acute thrombus has been removed. The AV access often occludes because of decreased flow due to an underlying narrowing, and this narrowing must be opened in order to prevent acute re-occlusion.

For purposes of reporting, the AV dialysis access is considered a single vessel from the arterial anastomosis through the axillary vein. All PTA done within this segment of vessel is coded as CPT codes 35476/75978 used once no matter how many focal lesions are treated within this segment. All PTA within the arteriovenous dialysis access "vessel" would be coded as a single PTA, regardless of the number of stenoses treated within this segment.

For AV dialysis native fistulae, the "vessel" is defined as the inflow artery at the AV anastomosis, the AV anastomosis, and the outflow vein to the level of the axillary vein. For AV dialysis grafts, the "vessel" is defined as the inflow artery at the arterial anastomosis, the arterial anastomosis, the entire length of the graft, the venous anastomosis, and the venous outflow to the level of the axillary vein. All PTA done within these defined segments would be coded as a single angioplasty.

Angioplasty may be coded a second time if a separate stenosis is treated in a central vessel (e.g., axillary, subclavian, brachiocephalic vein or artery, or SVC). The site of, and need for, separate stenosis treatment should be clearly documented. If central venous stenoses are treated, the venous angioplasty codes 35476 and 75978 should be used once to describe central venous angioplasty, even if more than one discrete central lesion must be treated.

There is one clinical situation that is an exception to the above. Arterial PTA may be necessary if there is an inflow arterial stenosis that is limiting flow through the dialysis access. If a PTA is performed at the arterial anastomosis of an AV dialysis access, it could be coded as 35475/75962. In this instance, all PTA done within the AV dialysis access "vessel" would still be coded as a single PTA but would be coded with the arterial codes (35475/75962) instead of the venous codes (35476/75978), and the venous codes would not be used for any other angioplasty performed within the AV dialysis access vessel. Arterial PTA codes are not submitted for simple removal of the arterial plug when performing a declot procedure.

4. Subject to FDA approval of specific devices, stents are covered if used as a last resort to salvage a graft or fistula. Placement of an intravascular stent (e.g. 37205-37206) and the associated supervision and interpretation (75960) may be appropriate in selected clinical scenarios. The following clinical scenarios are examples where a stent may be considered for payment:
- There is a PTA induced rupture,
- For graft salvage, (e.g., PTA is unsuccessful due to elastic recoil, stenosis has recurred or less than 3 months);
- For central veins stenosis or occlusion,
- aneurysm or pseudoaneurysm is present
See the policy on coverage of non-coronary vascular stents to receive more detailed information on stenting.

Open Surgical AV Dialysis Access and Maintenance Open surgical therapy for thrombosed or impaired AV dialysis access utilizes direct open access to the conduit and contiguous vessels. Mechanical fragmentation and surgical removal of occlusive thrombotic material is effected under direct visualization. Adjunctive thrombolytic pharmacotherapy may be employed. Residual vascular stenoses or obstructive lesions are removed and corrected using standard vascular surgical techniques (e.g., CPT codes 36831, 36832, 36833). Angiography is adjunctively employed, when appropriate and medically necessary, to assess the functional integrity of afferent and efferent vessels remote from the surgical field.

Limitations

1. The dispersing, maceration, and removal of thrombotic material are an integral part of cannula/shunt/fistula declotting or revision (36860, 36861, 36831, 36832, 36833 and 36870). It is not to be interpreted, or coded, as thrombectomy.

2. Intermittent boluses of anticoagulant or thrombolytic agents are integral to and included in the percutaneous thrombectomy of a dialysis access (36870) and are not separately coded. However, if a thrombus is present outside the graft and requires separately identifiable thrombolytic therapy, this portion of the procedure would be separately coded using 37201 and 75896 plus the appropriate catheterization code(s). This therapy typically involves additional selection of the vessel involved, negotiation of an infusion catheter into the thrombus and prolonged infusion of drug to dissolve the clot.

3. In the absence of clinical findings suggesting the need to re-establish appropriate flow in a dialysis fistula, it is seldom reasonable and necessary to perform diagnostic angiography or sonographic confirmatory studies as part of the decision to treat (i.e., 75710, 75790, 75820). It is included in the monthly composite rate paid to the physician.

Declotting by thrombolytic agent of implanted vascular access device or catheter (36593): This code reports declotting of completely implanted devices and catheters. This code is not to be used for routine flushing of vascular access devices with saline or heparin.
This procedure necessitates the use of a thrombolytic agent (e.g., Urokinase) that is introduced through a syringe and then slowly instilled into the device or catheter. (This is generally considered to be a single bolus of thrombolytic agent.)

4. If the central catheter is checked with fluoroscopy alone (not a port check but injection into central veins), either with injection of contrast or without, a fluoro code (76000) would be appropriate.
The injection of contrast material is not separately reportable and is inherent to the RS&I study.

5. Venography codes (75820, 75822, 75825, and 75827) may be reported in conjunction with AV dialysis access procedures. The venography codes are not to be coded to describe diagnostic evaluation of the AV dialysis access or its outflow, as evaluation of the entire venous outflow of the AV dialysis access is included in 36147. However, if the fistulagram shows that a new AV dialysis access may need to be surgically created (e.g., the existing AV dialysis access cannot be salvaged), it may be necessary to do diagnostic studies of the same limb or additional limbs in order to define where the next AV dialysis access should be placed. These separate diagnostic studies may be coded with the appropriate catheterization and RS&I codes that describe the service(s) provided.

6. Non-covered Conditions:
a. Medical record (e.g., procedure report) that does not verify that the services described by the submitted CPT codes were provided and/or medically necessary.
b. Services that are screening in nature (that are not providing clinically relevant information).
c. The placement of stent(s) in a vessel(s) for which there has been no objective symptoms or limitation of function is considered to be preventive, and therefore not covered by Medicare.
d. Placement of a stent (CPT codes 37205-37206) and the associated radiological supervision and interpretation service (CPT code 75960) in an AV access when there are no objective symptoms or limitation of function are considered preventative and therefore not covered.
e. When diagnostic non-invasive vascular studies are performed to evaluate an AV access on a routine basis in the absence of signs and symptoms, the services are considered monitoring, and are not separately covered by Medicare.
f. Use of a device that is not FDA approved will be considered investigational and not medically necessary.

Other Comments:
Bill type codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.

Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000)


Coding Information

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Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
018x Hospital - Swing Beds
021x Skilled Nursing - Inpatient (Including Medicare Part A)
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
028x Skilled Nursing - Swing Beds
072x Clinic - Hospital Based or Independent Renal Dialysis Center
085x Critical Access Hospital

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.
0320 Radiology - Diagnostic - General Classification
0329 Radiology - Diagnostic - Other Radiology - Diagnostic
0360 Operating Room Services - General Classification
0361 Operating Room Services - Minor Surgery
0369 Operating Room Services - Other OR Services
0450 Emergency Room - General Classification
0490 Ambulatory Surgical Care - General Classification
0520 Free-Standing Clinic - General Classification
0521 Free-Standing Clinic - Clinic Visit by Member to RHC/FQHC
0920 Other Diagnostic Services - General Classification
0929 Other Diagnostic Services - Other Diagnostic Service
0960 Professional Fees - General Classification
0981 Professional Fees - Emergency Room Services
0982 Professional Fees - Outpatient Services
0983 Professional Fees - Clinic

CPT/HCPCS Codes
35475 TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; BRACHIOCEPHALIC TRUNK OR BRANCHES, EACH VESSEL
35476 TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; VENOUS
35903 EXCISION OF INFECTED GRAFT; EXTREMITY
36005 INJECTION PROCEDURE FOR EXTREMITY VENOGRAPHY (INCLUDING INTRODUCTION OF NEEDLE OR INTRACATHETER)
36010 INTRODUCTION OF CATHETER, SUPERIOR OR INFERIOR VENA CAVA
36120 INTRODUCTION OF NEEDLE OR INTRACATHETER; RETROGRADE BRACHIAL ARTERY
36140 INTRODUCTION OF NEEDLE OR INTRACATHETER; EXTREMITY ARTERY
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)
36148 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)
36215 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY
36216 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY
36217 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY
36218 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; ADDITIONAL SECOND ORDER, THIRD ORDER, AND BEYOND, THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY (LIST IN ADDITION TO CODE FOR INITIAL SECOND OR THIRD ORDER VESSEL AS APPROPRIATE)
36245 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY
36246 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY
36247 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY
36593 DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCESS DEVICE OR CATHETER
36831 THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)
36832 REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)
36833 REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)
36838 DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)
36870 THROMBECTOMY, PERCUTANEOUS, ARTERIOVENOUS FISTULA, AUTOGENOUS OR NONAUTOGENOUS GRAFT (INCLUDES MECHANICAL THROMBUS EXTRACTION AND INTRA-GRAFT THROMBOLYSIS)
37201 TRANSCATHETER THERAPY, INFUSION FOR THROMBOLYSIS OTHER THAN CORONARY
37607 LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA
75791 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
75820 VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION
75822 VENOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION
75825 VENOGRAPHY, CAVAL, INFERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION
75827 VENOGRAPHY, CAVAL, SUPERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION
75896 TRANSCATHETER THERAPY, INFUSION, ANY METHOD (EG, THROMBOLYSIS OTHER THAN CORONARY), RADIOLOGICAL SUPERVISION AND INTERPRETATION
75962 TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL ARTERY OTHER THAN CERVICAL CAROTID, RENAL OR OTHER VISCERAL ARTERY, ILIAC OR LOWER EXTREMITY, RADIOLOGICAL SUPERVISION AND INTERPRETATION
75964 TRANSLUMINAL BALLOON ANGIOPLASTY, EACH ADDITIONAL PERIPHERAL ARTERY OTHER THAN CERVICAL CAROTID, RENAL OR OTHER VISCERAL ARTERY, ILIAC AND LOWER EXTREMITY, RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
75978 TRANSLUMINAL BALLOON ANGIOPLASTY, VENOUS (EG, SUBCLAVIAN STENOSIS), RADIOLOGICAL SUPERVISION AND INTERPRETATION
76000 FLUOROSCOPY (SEPARATE PROCEDURE), UP TO 1 HOUR PHYSICIAN TIME, OTHER THAN 71023 OR 71034 (EG, CARDIAC FLUOROSCOPY)
J0350 INJECTION, ANISTREPLASE, PER 30 UNITS
J2993 INJECTION, RETEPLASE, 18.1 MG
J2997 INJECTION, ALTEPLASE RECOMBINANT, 1 MG

ICD-9 Codes that Support Medical Necessity
Note: ICD-9 codes must be coded to the highest level of specificity.
XX000 Not Applicable


Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

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Documentations Requirements
Documentation supporting the medical necessity, such as ICD-9-CM diagnosis codes, must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.

Angiographic/ultrasound report studies may be required to document the need for angioplasty of arterial and venous vessels at the same setting.

The operative report and medical record must document the services reported and be made available to Medicare upon request
Appendices
Utilization Guidelines
1. For services that exceed the accepted standard of medical practice and may be deemed not medically necessary, the provider/supplier must provide the patient with an acceptable advance notice of Medicare's possible denial of payment. A waiver of liability should be signed when a provider/supplier does not want to accept financial responsibility for the service.
2. Services performed for percutaneous interventions to treat total occlusion of graft due to thrombus of more than one year in duration will be denied as not reasonable and medically necessary.
3. Angioplasty of vessels not documented to be significantly stenosed by angiography or ultrasound will be denied.
4. Dilatation of both limbs of the fistula will be denied unless significant obstruction is documented in both limbs.
5. Dilation of the graft anastomotic site will be considered either arterial or venous but not both.
6. Procedure codes 35475 and 35476 performed on the same day will be denied without documentation of anatomically separate lesions. Code 35475 may be reported for angioplasty of an inflow lesion that is proximal to the graft while 35476 may be reported for PTA of the venous anastomosis and/or venous outflow. 35475 and 35476 should not be reported on the same day for the graft alone since it is considered a single vessel for the purposes in this policy.
7. Services performed with excessive frequency will be denied as not medically necessary. Frequency is considered excessive when services are performed more frequently than generally accepted by peers and reasons for additional services are not justified by documentation.
Sources of Information and Basis for Decision
Other Carrier policies including Empire
Kidney Disease Outcomes Quality Initiative (KDOQI), Clinical practice guidelines for vascular access, update 2006, National Kidney Foundation (kidney.org)
Vorwerk, Dierk; Percutaneous intervention to Support Failing Hemodialysis Fistulas and Grafts, Kidney Blood Press Res 1997;20:145-147
Gray, Richard J. Percutaneous Intervention for Permanent Hemodialysis Access: A Review, SCVIR, May-June 1997
Gray, Richard J. et al; Reporting Standards for Percutaneous Intervention in dialysis Access, special communication; November-December 1999 JVIR.
Sands, Jeffrey J., et al; Intervention Based on Monthly Monitoring Decreases Hemodialysis Access. Thrombosis; ASAIO Journal 1999; 45:147-150.
Patel, R et al; Patency of Wallstents Placed across the Venous Anastomosis of Hemodialysis Grafts after Percutaneous Recanalization ; November 1998
Treatment of Hemodialysis-related Central Venous Stenosis or Occlusion: Results of Primary Wallstnet Haage, P. et al; Placement and Follow-up in 50 patients; July 1999.
Welber, A. et al; Endovascular Stent Placement for Angioplasty-induced Venous Rupture Related to the Treatment of Hemodialysis Grafts; SCVIR 1999.
Gelbfish, Gary. A.; Surgical Care of the Arteriovenous Graft: Issues for the Interventionalist FACS, Techniques in Vascular and Interventional Radiology, Vol 2, No 4, (December), 1999: pp 179-185
Schwab, Steve J.; Assessing the Adequacy of Vascular Access and Its Relationship to Patient Outcome, American Journal of Kidney Diseases, Vol 24, No 2 (August), 1994: pp 316-320.
Siday AN, Spergel LM, Besarab A, et al.; The Society for Vascular Surgery: Clinical practice guidelines for the surgical placement and maintenance of arteriovenous hemodialysis access. J Vasc Surg. 2008; 48:2S-25S.
Aruny, John E. et al for the Society of Interventional Radiology Standards of Practice Committee; Quality Improvement Guidelines for Percutaneous Management of the Thrombosed
or Dysfunctional Dialysis Access; J Vasc Interv Radiol, 2003; 14:S247S253
Brown, Daniel B. et al for the Society of Interventional Radiology Standards of
Practice Committee; Quality Improvement Guidelines for Diagnostic Infusion Venography
J Vasc Interv Radiol, 2003; 14:S289S292
Hentschel, Dirk M.; Vascular Access for Hemodialysis; Nephrology Rounds January 2008,
Volume 6, Issue 1 (nephrologyrounds.org)
Lomonte, Carlo and Basile, Carlo, The role of nephrologist in the management of vascular access
Editorial Comment; Nephrol Dial Transplant, (2011) 0: 13
Advisory Committee Meeting Notes
Meeting Date:
Wisconsin 05/20/2011
Illinois 05/25/2011
Michigan 05/18/2011
Minnesota 05/19/2011
Iowa, Kansas, Missouri and Nebraska 0617/2011
Open Meeting: 04/28/2011

*- An asterisk indicates a revision to that section of the policy.

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction.

Start Date of Comment Period
06/17/2011
End Date of Comment Period
08/01/2011
Start Date of Notice Period
Revision History Number
Revision History Explanation
Reason for Change
Last Reviewed On Date
04/01/2011
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