CPT Code: 35500Procedure: Harvest of upper extremity vein, one segment, for lower extremity bypass procedure(List separate...
•       Code 35681 identifies 1) the harvest of the vessel from a location separate from the graft site,and 2) the assimil...
Description of Procedure: A laparotomy is performed under general anesthesia. Following a routineabdominal exploration, th...
•        the code includes harvesting of veins from locations other than locally at the bypass graft site;•       the code...
add-on work. At each additional vein harvest site, the skin and soft tissue are dissected to expose thevein. Side branches...
Topical papaverine is often administered to prevent venospasm. Once adequate length is obtained, theveins are ligated at b...
CPT Code: 35686Procedure: Creation of distal arteriovenous fistula during lower extremity bypass surgery (non-hemodialysis...
•       See code 36831 for thrombectomy of an autogenous or non-autogenous dialysis graft.•        If a thrombectomy is pe...
CPT Code: 35905Procedure: Excision of infected graft; thoraxDescription of Procedure:        N/ACoding Tips: The types of ...
Description of Procedure: This procedure involves the surgical placement of an arterial catheter, intothe hepatic artery o...
36556            Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older36575          ...
may be made next to the wire to enlarge the opening) and into a vein of the thoracic cavity    (usually the subclavian, in...
•     Devices Commonly Used: Groshong, Broviac (used commonly in children), Hickmann,         Intrasil, Centrasil, PPIC, C...
36578           Replacement, catheter only, of central venous access device, with subcutaneous port or                pump...
Revision of Pump:   •      The infusion pump is usually in need of repair due to breakage of the catheter or failure of th...
CPT Codes/Procedures:36557            Insertion of tunneled centrally inserted central venous catheter, without subcutaneo...
CPT Codes/Procedures:36560          Insertion of tunneled centrally inserted central venous access device, with subcutaneo...
addition to the external access site(s), partially implanted devices travel beneath the skin    before entering the vein. ...
CPT Codes/Procedures:36568           Insertion of peripherally inserted central venous catheter (PICC), without subcutaneo...
CPT Codes/Procedures:36595            Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from cen...
Description of Procedure:The term midline catheter is used by many different individuals to describe different types of pe...
This procedure is similar to a venipuncture, except that it involves an artery.Common Therapeutic Indications: N/ADevices ...
directly into the artery near the liver. The catheter is then brought out through the skin and the incisionclosed.Common T...
resecting the veins or removing the clot. If these procedures are not successful or indicated, the cannulais removed and t...
Common Therapeutic Indications:This approach is often performed in patients with large or obese arms.CPT Code: 36819Proced...
Procedure: Insertion of arterial and venous cannula(s) for isolated extracorporeal circulation includingregional chemother...
Description of Procedure: In these procedures, when arteriovenous fistulae placed for dialysis (madeof autogenous vein or ...
•       According to the AMA, assign code 36832 if an angioplasty is performed on an A-V fistula.Blood flow through the di...
Description of Procedure: For those instances wherein both arteriovenous fistula revision andthrombectomy is performed, co...
Common Therapeutic Indications: N/ADevices Commonly Used: N/ACPT Code: 36838Procedure: Distal revascularization and interv...
Coding Tips: CommentsClot: Coagulation of blood within the cannula.Thrombus: An organized clot is present in the A-V fistu...
Code 36870 is designed to cover any of these methods or combinations of these methods, and is usedonly to describe the act...
CPT Code: 35901.doc
CPT Code: 35901.doc
CPT Code: 35901.doc
CPT Code: 35901.doc
CPT Code: 35901.doc
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CPT Code: 35901.doc

  1. 1. CPT Code: 35500Procedure: Harvest of upper extremity vein, one segment, for lower extremity bypass procedure(List separately in addition to code for primary procedure)Description of Procedure: This code describes the harvest of a single vein segment from the upperextremity that is later used in a lower extremity bypass procedure. Lower extremity bypasses, especiallybypasses traversing the knee are best performed with autogenous vein tissue. The best choice is thegreater saphenous vein. However, in some patients where a lower extremity vein (greater saphenous orlesser saphenous vein) is not available, a vein needs to be harvested from the upper extremity. Code35500 may be used to describe harvesting an arm vein to be used as an autogenous venous conduit inlower extremity bypasses especially those traversing the knee joint.Patients requiring distal lower extremity bypasses who have absent or inadequate lower extremityautogenous veins may require arm vein harvest and therefore the use of this add-on code. This isestimated to be about 5-10% of total lower extremity bypasses.This technique has a widespread usage and has been used for many years (more than 25-30 years) asan alternative to using the saphenous vein as the conduit in cases where the saphenous vein inunavailable due to prior use.Upper extremity veins (the cephalic and or the basilic) are usually more difficult to dissect and require thepreparation and draping of a field completely separate from the site of the lower extremity bypassprocedure. In addition, harvesting arm veins may influence the type of anesthesia used. Whereas forlower extremity bypass procedures performed with a lower extremity vein where an epidural or spinalanesthesia can be used, bypasses performed with arm vein require general anesthesia or a combinationof epidural and axillary block. Furthermore, upper extremity veins are usually thinner and have morebranches to control, which make their dissection more time consuming.Intra-service work involved in harvest of the upper extremity vein includes dissection of the overlying skinand soft tissue for the length of conduit required. There is no “typical” length. Often the incision extendsfrom shoulder to wrist. Alternatively, a long conduit may be obtained with an incision extending down thearm over the basilic vein, medial to lateral over the antecubital vein, and then back up the arm over thecephalic vein. The venous side branches are identified, ligated, and divided. Topical papaverine isadministered to prevent venospasm. Once an adequate length is obtained, the vein is ligated at bothends and excised. The vein is flushed with heparinized saline, gently distended, and tested for leaks.#7-0 polypropylene sutures are used to repair leaks, and the surgeon wears ocular loupe magnification toperform these maneuvers. The vein is transferred to the bypass site of the leg, and the bypass surgery iscompleted. Thereafter, attention returns to the arm vein harvest site. Closure entails irrigation, routinehemostasis maneuvers, suture of the subcutaneous tissue, skin closure with sutures or staples, andapplication of a dressing. Although the arm wounds are occasionally problematic, the typical patient hasno postoperative wound problems related to arm vein harvest.Coding Tips:• As with other CPT “add-on” codes, code 35500 is to be reported in addition to the definitive non-hemodialysis bypass graft (e.g. femoral-popliteal bypass) procedure performed.• The harvest of autogenous from upper extremity veins (the cephalic and or the basilic) is usuallymore difficult than from the lower veins since the dissection is more difficult and requires the preparationand draping of a field completely separate from the site of the lower extremity bypass procedure. Inaddition, harvesting arm veins may influence the type of anesthesia used.• Furthermore, upper extremity veins are usually thinner and have more branches to control, whichmake their dissection more time consuming. Therefore a new code 35500 was added describing theharvest of a single upper extremity vein for lower extremity bypass procedures.
  2. 2. • Code 35681 identifies 1) the harvest of the vessel from a location separate from the graft site,and 2) the assimilation of the two components of the composite graft (i.e., the joining of the prostheticgraft material to the autogenous vein.) As a result, it should be used to identify the harvest of theautogenous vessel and the creation of the composite graft vein for the grafting procedure. Since code35681 is an add-on code, it is reported in addition to the appropriate bypass graft code (35501-35587).Common Therapeutic Indications:This procedure is usually used in patients who have symptomatic ischemia of the lower extremitymanifested by claudication, rest pain, or tissue loss, when these patients do not have a complete segmentof greater saphenous vein available.CPT Code: 35646Procedure: Bypass graft, with other than vein; aortobifemoralDescription of Procedure: A laparotomy is performed under general anesthesia. Following a routineabdominal exploration, the small bowel is mobilized toward the patient’s right side. The retroperitoneumis incised, and the aorta is exposed along its entire length from just beyond the renal artery origins to theaortic bifurcation. Complete circumferential dissection of the proximal aorta is performed in order to placea vascular cross clamp. The proximal common iliac arteries are exposed in a similar manner, care beingtaken to avoid injury to the ureters. The retroperitoneum is elevated over the iliac arteries in the pelvis onboth sides to create tunnels for the graft limbs.Attention is directed to the groins where incisions are performed over the common femoral arteries. Thesoft tissue is dissected until the femoral arteries are encountered. The distal common femoral artery andproximal superficial and profunda femoral arteries are dissected and isolated bilaterally in a region longenough to achieve vascular control and perform the graft anastomoses.A tunnel is completed between the femoral regions on each side and the abdominal cavity. This oftenrequires ligation of multiple crossing veins. Hemostasis is achieved. Intravenous heparin is administeredfor anticoagulation. A bifurcated synthetic graft is passed onto the surgical field. Proximal and distalvascular control of the aorta is obtained, and cross clamps are placed. An anastomosis is performedbetween the aorta and the proximal end of the bifurcated graft. Clamps are removed, and extra suturesare placed as required to achieve anastomotic hemostasis.One graft limb is passed through each tunnel between abdomen and groins. The graft is checked tomake sure there are no kinks or twists. Starting on either side first, vascular clamps are placed at thefemoral bifurcation, and an arteriotomy is performed. The graft limb is cut to appropriate length, and ananastomosis is performed between the graft limb and the femoral artery. Vascular clamps are removed,and the anastomosis is checked for hemostasis. Additional sutures are placed as required.The aortic graft limb to the femoral artery anastomosis on the opposite side is performed in the identicalfashion and blood flow is restored. Both the lower extremities are checked to confirm adequate perfusion.The abdominal cavity is checked once again for hemostasis, and appropriate maneuvers are performedas needed. The abdomen is irrigated with saline, and the viscera are replaced. The retroperitoneum isreapproximated to prevent contact between the new aortic graft and the bowels. The laparotomy isclosed. The groin incisions are then closed. Irrigation and inspection is performed for hemostasis. Next,the subcutaneous tissue is closed in multiple layers, and the skin is stapled or sutured.CPT Code: 35647Procedure: Bypass graft, with other than vein; aortofemoral
  3. 3. Description of Procedure: A laparotomy is performed under general anesthesia. Following a routineabdominal exploration, the small bowel is mobilized towards the patient’s right side. The retroperitoneumis incised, and the aorta is exposed along its entire length from just beyond the renal artery origins to theaortic bifurcation. Complete circumferential dissection of the proximal aorta is performed in order to placea vascular cross clamp. The proximal right common iliac artery is exposed in a similar manner, carebeing taken to avoid injury to the ureters. The retroperitoneum is elevated over the right iliac artery tocreate a tunnel for the graft limb.Attention is directed to the right groin where an incision is performed over the common femoral artery.The soft tissue is dissected until femoral artery is encountered. The distal common femoral, and theproximal superficial and profunda femoral arteries are dissected at the femoral bifurcation. These areisolated in a region long enough to achieve vascular control and perform the graft anastomosis.A tunnel is completed between the femoral region and the abdominal cavity. This oftentimes requiresligation of multiple crossing veins. Hemostasis is achieved. Intravenous heparin is administered foranticoagulation. A tubular synthetic graft is passed onto the surgical field. Proximal and distal vascularcontrol of the aorta is obtained, and cross clamps are placed. An anastomosis is performed between theaorta and the proximal end of the bifurcated graft. Clamps are removed, and extra sutures are placed asrequired to achieve anastomotic hemostasis.The graft limb is passed through the tunnel created between the abdomen and the groin incision. Thegraft is checked to make sure there are no kinks or twists. Vascular clamps are placed at the femoralbifurcation, and an arteriotomy is performed. The graft limb is cut to appropriate length, and ananastomosis is performed between the graft and the femoral artery. Vascular claps are removed, andhemostasis is achieved with additional sutures as required.CPT Code: 35681Procedure: Bypass graft; composite, prosthetic and vein (List separately in addition to code forprimary procedure)Description of Procedure: This code describes performance of a bypass operation of which the conduitis made out of two segments of different graft material; a segment of autogenous vein and segment ofprosthetic graft taken off the shelf. Such a conduit is usually needed in situations where a segment ofautogenous vein is not available in adequate length to perform an all-autogenous venous tissue bypass.Such situations occur in patients with previous cardiac procedures, lower extremity bypass procedures, orin situations where the vein is unsuitable to use due to multiple branching which leads to very small veinsize or due to sclerosis of the vein.There is no pre-or post-service work. Intra-service work begins with construction of the composite graft.Appropriately sized synthetic graft material is chosen and brought onto the operative field. The syntheticgraft is cut to match the size requirements.Fine suture is used to sew the vein and synthetic material. The suture line is tested for hemostasis, andadditional sutures are placed as required. The bypass graft (a separately reportable procedure) is thencompleted.Coding Tips:• CPT code 35681 is an add-on code revised to clarify the differing composition of the bypass graftplaced and to offer a more clear definition that this code is to be used only when prosthetic graft is addedto a vein to form the composite graft.
  4. 4. • the code includes harvesting of veins from locations other than locally at the bypass graft site;• the code is only reported in addition to bypass graft codes 35501-35587;• the reporting does not allow for a “stair-step” coding convention, (therefore, only one code shouldbe reported identifying the number of venous segment(s) harvested;• When more than one venous segment is required to create an appropriate length venous conduit,the anastomosis of those vessels is included in codes 35681-35683.• With the exception of code 35681, the two sets of codes 35681–35683 and 35501–35587 identifyvenous procedures (code 35681 identifies a composite procedure, which involves the use of both venousmaterial and prosthetic material). Therefore, since the 35501-35587 codes all involve the use of venousmaterial alone, the codes in 35681-35683 series are used to identify the composite grafting proceduresperformed for the specific bypass procedures included in the 35501-35587 series.Common Therapeutic Indications:This procedure is used for patients who have symptomatic ischemia of the lower extremity manifested byclaudication, rest pain, or tissue loss, in the absence of a complete segment of greater saphenous vein.CPT Code: 35682Procedure: Bypass graft; autogenous composite, two segments of veins from two locations (Listseparately in addition to code for primary procedure)Description of Procedure: This procedure describes the harvest and anastomosis of multiple veinsegments from distant sites for use as arterial bypass graft conduits. This code is intended for use whenthe two vein segments are harvested from a limb other than that undergoing bypass.This code describes the harvesting and anastomosis of two segments of vein from two anatomic sites foruse as an arterial bypass graft conduit. Lower extremity bypasses, especially bypasses traversing theknee are best done with autogenous vein tissue. The best choice is the greater saphenous vein.However, in some patients where greater saphenous vein is not available in its entirety, segments of veinneed to be harvested from different locations and anastomosed to each other to obtain a conduit longenough to be used for the bypass.This particular procedure requires dissection of two segments of venous tissue. Oftentimes the search foran extra vein is an unanticipated event that becomes necessary only after the surgeon has spent asubstantial amount of time working with the greater saphenous before making the determination that aportion of it is inadequate. In addition, the dissection of venous tissue is a time consuming procedure. Itrequires making an incision over the area of the vein, its dissection from the surrounding tissue, and thedouble ligation and severance of all vein branches. The segment of vein is then removed from itslocation. The same technique is repeated in the harvest of a segment of vein from another location. Thenan anastomosis is performed between the two free segments. This, newly created, longer autogenousvenous tissue segment, is used to perform the bypass. Obviously, this procedure requires more workthan placement of a composite bypass made of one segment of vein and a prosthetic bypass graft takenoff the shelf (i.e., code 35681). The prosthetic bypass graft, obviously, does not need to be harvested.This code requires work in excess of 35681, including identification of the alternate site, re-preparationand re-drape if required, skin incision, vein identification and exposure, vein branch ligation, harvest sitehemostasis, and harvest site closure.Prior to this operation, a review of duplex ultrasound or other studies is necessary to determine the bestsuitable segments of vein to use for the bypass graft. Also, additional supervision of the positioning,prepping, and draping of the additional limb or limbs to be used for vein harvest is directly related to this
  5. 5. add-on work. At each additional vein harvest site, the skin and soft tissue are dissected to expose thevein. Side branches are identified, ligate, and divided. Topical papaverine is often administered toprevent venospasm. Once adequate length is obtained, the veins are ligated at both ends and excised.The venous conduits are flushed with heparinized saline, gently distended and tested for leaks. A veryfine polypropylene suture is used to repair the leaks as found, and the surgeon typically employs ocularloupe magnification to avoid reduction of the lumen by these sutures. In order to form a single longconduit, the ends of the two segments are beveled, then sutured together, again using very fine sutureand loupe magnification. The anastomosis is tested for leaks, and these are repaired as needed. Thenewly constructed conduit is then employed for completion of the bypass graft (a separately billable CPTprocedure). Directly related to this procedure is the achievement of hemostasis in the distant vein harvestsites, plus subcutaneous and skin closure of these sites, and application of sterile dressings. Wound careand analgesia required for the additional vein harvest sites also adds to the postoperative work.Coding Tips:• The code includes harvesting of veins from locations other than locally at the bypass graft site;• The code is only reported in addition to bypass graft codes 35501-35587;• The reporting does not allow for a “stair-step” coding convention, (therefore, only one code shouldbe reported identifying the number of venous segment(s) harvested;• When more than one venous segment is required to create an appropriate length venous conduit,the anastomosis of those vessels is included in codes 35681-35683.• With the exception of code 35681, the two sets of codes 35681–35683 and 35501–35587 identifyvenous procedures (code 35681 identifies a composite procedure, which involves the use of both venousmaterial and prosthetic material). Therefore, since the 35501-35587 codes all involve the use of venousmaterial alone, the codes in 35681-35683 series are used to identify the composite grafting proceduresperformed for the specific bypass procedures included in the 35501-35587 series.CPT Code: 35683Procedure: Bypass graft; autogenous composite, three or more segments of vein from two ormore locations (List separately in addition to code for primary procedure)Description of Procedure: CPT code 35683 describes the harvesting and anastomosis of three ormore segments of vein from two or more anatomic sites for use as an arterial bypass graft conduit.Again, this procedure requires more work since ore than two segments need to be harvested fromdifferent locations and anastomosed together to obtain a conduit of autogenous venous tissue longenough to perform the bypass. This requires even more work than harvesting two segments of vein. Thisprocedure is somewhat comparable to the one previously described. However, in this case, threesegments of veins or more are harvested from different locations in the body. Those locations could bethe lesser saphenous vein in the same leg or the opposite leg, segment of vein from the upper extremity,or segment of greater saphenous vein from the same or the contra-lateral extremity. Two or moreanastomoses are used to connect all the segments together to obtain enough length to perform an all-autogenous vein bypass.Prior to this operation, a review of duplex ultrasound or other studies is necessary to determine the bestsuitable segments of vein to use for the bypass graft. Also, additional supervision of the positioning,prepping, and draping of the additional limb or limbs to be used for vein harvest is directly related to thisadd-on work. At each additional vein harvest site, the skin and soft tissue are dissected to expose thevein. Side branches are identified, ligate, and divided.
  6. 6. Topical papaverine is often administered to prevent venospasm. Once adequate length is obtained, theveins are ligated at both ends and excised. The venous conduits are flushed with heparinized saline,gently distended and tested for leaks. A very fine polypropylene suture is used to repair the leaks asfound, and the surgeon typically employs ocular loupe magnification to avoid reduction of the lumen bythese sutures. In order to form a single long conduit, the ends of the two segments are beveled, thensutured together, again using very fine suture and loupe magnification. The anastomosis is tested forleaks, and these are repaired as needed.For 35683, this beveling/anastomosis/testing/ repairing sequence is repeated until all vein segments havebeen joined. The newly constructed conduit is then employed for completion of the bypass graft (aseparately billable CPT procedure). Directly related to this procedure is the achievement of hemostasis inthe distant vein harvest sites, plus subcutaneous and skin closure of these sites, and application of steriledressings. Wound care and analgesia required for the additional vein harvest sites also adds to thepostoperative work.Coding Tips:• The code includes harvesting of veins from locations other than locally at the bypass graft site;• The code is only reported in addition to bypass graft codes 35501-35587;• The reporting does not allow for a “stair-step” coding convention, (therefore, only one code shouldbe reported identifying the number of venous segment(s) harvested;• When more than one venous segment is required to create an appropriate length venous conduit,the anastomosis of those vessels is included in codes 35681-35683.• With the exception of code 35681, the two sets of codes 35681–35683 and 35501–35587 identifyvenous procedures (code 35681 identifies a composite procedure, which involves the use of both venousmaterial and prosthetic material).Therefore, since the 35501-35587 codes all involve the use of venous material alone, the codes in35681-35683 series are used to identify the composite grafting procedures performed for the specificbypass procedures included in the 35501-35587 series.CPT Code: 35685Procedure: Placement of vein patch or cuff at distal anastomosis of bypass graft, synthetic conduit (Listseparately in addition to code for primary procedure)Description of Procedure: The surgeon isolates 2 cm more tibial artery than would be required for aroutine distal anastomosis. A skin incision at a distant site is made to harvest vein patch/cuff to find andisolate 6-8 cm vein, ligate vein branches, ligate inflow and outflow ends of donor vein, and resect donorvein. The surgeon opens the harvested vein in longitudinal fashion and performs modified distalanastomosis of bypass graft using harvested vein as patch or cuff. Sutures are placed with 7-0Polypropylene using loupe magnification, the vein donor site is irrigated, while achieving hemostasis atthe vein donor site. Subcutaneous tissue and skin is closed at the vein donor site.Coding Tip:Code 35685 represents placement of an interposition of venous tissue (vein patch or cuff) at theanastomosis between the synthetic bypass conduit and the involved artery. Source: September 2002CPT Assistant newsletter, AMA.
  7. 7. CPT Code: 35686Procedure: Creation of distal arteriovenous fistula during lower extremity bypass surgery (non-hemodialysis) (List separately in addition to code for primary procedure)Description of Procedure: An extra 3-5 cm of the tibial artery is dissected as well as 3 – 5 cm of thetibial vein is dissected. The vein branches are ligated, with ligation of the inflow/outflow end of the donorvein. Occlusion of venous back bleeding is performed by a temporary micro clip. A longitudinal incisionin the vein is performed with a modified distal bypass anastomosis. To include the vein. Sutures areplaced with 7-0 Polypropylene using loupe magnification. The microclip is removed, and the vein donorsite is irrigated, while achieving hemostasis at the vein donor site.Coding Tip:Code 35686 describes the use of autogenous vein to create a fistula between the tibial or peroneal arteryand vein at or beyond the distal bypass anastomosis site of the involved artery. Source: September 2002CPT Assistant newsletter, AMA.CPT Code: 35875Procedure: Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula);Description of Procedure: This procedure involves the removal of a blood clot, or thrombus, from avenous, in situ venous or arteriovenous bypass graft (see CPT codes 35501–35683). Bypass grafts arecreated surgically using synthetic material or the patient’s veins. The physician opens the bypass graftand uses a balloon Fogarty catheter to remove the thrombus.In surgery, the graft and the femoral artery were dissected via an incision placed in the femoral area. Anincision was made in the hood of the graft at the femoral anastomosis and a Fogarty balloon catheter wasused to do thrombectomy of the graft. The common femoral artery is patent with brisk arterial inflow. Anintraoperative arteriogram showed that there was progression of arteriosclerotic disease in the poplitealartery distal to the area of the popliteal anastomosis. This progression of the disease was probably thecause for the failure of the bypass. Therefore, via a separate incision in the popliteal area, the distal endof the graft and the popliteal artery were dissected and a jump graft is performed, either with a prostheticmaterial or autogenous vein conduit, from the previous dormant femoral-popliteal graft down to thepopliteal artery distal to the area of disease progression. Postoperatively, the patient was evaluatedfrequently for adequate circulation in the lower extremity by pulse checks and Doppler signals and anklepressures. In addition, the patient was followed closely postoperatively to detect and treat possiblecomplications such as re-thrombosis of the graft, muscle ischemia leading to compartment syndrome andrenal injury from myoglobinuria, bleeding, or infection.Code 35875 describes the thrombectomy of arterial or venous bypass placed originally to relieve limbischemia or to bypass a venous occlusion (i.e. not an autogenous or non-autogenous hemodialysis graft).Reporting the distinction between non-hemodialysis versus hemodialysis graft thrombectomy wasnecessary because the thrombectomy of an arterial or venous bypass is a more complicated procedurethan thrombectomy of an arterio-venous dialysis access. Therefore, adding the phrase “other thanhemodialysis graft or fistula” will restrict the use of this code as intended.The thrombectomy procedure described by code 35875 is used for patients with prosthetic graft originallyplaced, for example, for limb ischemia, requiring thrombectomy for occlusion and thrombosis.Coding Tips:• Code 35875 is used for an open thrombectomy of other than a hemodialysis graft or fistula.
  8. 8. • See code 36831 for thrombectomy of an autogenous or non-autogenous dialysis graft.• If a thrombectomy is performed on two separate grafts of two different vessels (arteries or veins)through the same incision, each thrombectomy would be reported separately, despite the fact that accesswas through the same incision for both thrombectomies. Modifier –59 (Distinct Procedural Service)should be appended to the second thrombectomy procedure to indicate that it was performed on adifferent anatomic vessel. (Source: CPT Assistant newsletter, April 2000, page 10).Common Therapeutic Indications: Clotted graftDevices Commonly Used: N/ACPT Code: 35876Procedure: Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula);with revision of arterial or venous graftDescription of Procedure: The removal of a blood clot, or thrombus, from a venous, in situ venous orarteriovenous bypass graft with repair (see codes 35901–35907 for removal of an infected graft).Coding Tips: N/ACommon Therapeutic Indications: Clotted graftDevices Commonly Used: N/ACPT Code: 35901Procedure: Excision of infected graft; neckDescription of Procedure: This procedure involves excising an infected bypass graft or arteriovenous(A-V) fistula/graft. An A-V fistula/graft is removed when it becomes occluded with a blood clot, orthrombus, and is also infected. Synthetic material frequently used for grafting is more likely to becomeinfected than a patient’s natural arteries and veins.Coding Tips: The types of bypass grafts located in the neck are carotid, carotid-subclavian, subclavian-subclavian, subclavian-axillary, carotid-vertebral, subclavian-vertebral.Common Therapeutic Indications: N/ADevices Commonly Used: N/ACPT Code: 35903Procedure: Excision of infected graft; extremityDescription of Procedure: N/ACoding Tips: The types of bypass grafts located in the extremities are axillary-femoral, axillary-popliteal,axillary-tibial, bifemoral, axillary-axillary, axillary-femoral-femoral, femoral-femoral, femoral-popliteal,femoral-anterior tibial, femoral-posterior tibial, femoral-peroneal artery, popliteal-tibial, popliteal-peronealartery.
  9. 9. CPT Code: 35905Procedure: Excision of infected graft; thoraxDescription of Procedure: N/ACoding Tips: The types of bypass grafts located in the thorax are aortosubclavian, aortocarotid.CPT Code: 35907Procedure: Excision of infected graft; abdomenDescription of Procedure: N/ACoding Tips: The types of bypass grafts located in the abdomen are aortoceliac, aortomesenteric,aortorenal, splenorenal, aortoiliac, aortofemoral, aortofemoral-popliteal, ilioiliac, and iliofemoral.CPT Code: 36002Procedure: Injection procedures (e.g., thrombin) for percutaneous treatment of extremitypseudoaneurysmDescription of Procedure: Frequently done as an outpatient procedure, percutaneous injection is usedto treat iatrogenic pseudoaneurysms of the upper and lower extremities. This technique differs markedlyfrom other therapies used to treat extremity pseudoaneurysms.The leak is detected by a separately reported duplex examination demonstrating a pseudoaneurysmarising from the artery. Using imaging guidance for accurate positioning a catheter is introduced into thepseudoaneurysm, with an attached syringe containing thrombin solution. Small amounts of the thrombinmixture are injected into the pseudoaneurysm under guidance until total thrombosis of thepseudoaneurysm is demonstrated.Common Therapeutic Indications: Iatrogenic pseudoaneurysms may occur following arterialcannulation for vascular diagnostic and therapeutic procedures. The puncture site in the artery fails toseal, allowing blood to leak into the surrounding soft tissue. Rather than leaking diffusely through thetissue, the blood is contained in a mushroom shaped cavity that develops adjacent to the needle hole inthe artery. This cavity is the actual “pseudoaneurysm. Blood rushed from the artery into thepseudoaneurysm with each systolic heartbeat then flows back from pseudoaneurysm to artery duringdiastole. The hematoma is contained or “constrained” by the local tissues which forms a false orpseudoaneurysm.Coding Tip: It would not be appropriate to additionally report CPT codes 36000 introduction of needle orintracatheter, vein and 90782-90799 Therapeutic, prophylactic, or diagnostic injections as these areintegral components of this procedure.CPT Code: 36260Procedure: Insertion of implantable intra-arterial infusion pump (e.g., for chemotherapy of liver)
  10. 10. Description of Procedure: This procedure involves the surgical placement of an arterial catheter, intothe hepatic artery of the liver through a surgical incision in the abdomen. It is then brought out andattached to an infusion pump. The infusion pump, approximately the size of a silver dollar, holds 10 to 15cc of fluid. The entire pump fits underneath the skin, similar to a pacemaker generator, creating a lumpunder the skin at the site. When access to the site is needed to fill the infusion pump, a needle is insertedinto the pump’s reservoir.Common Therapeutic Indications: Carcinoma of the liverDevices Commonly Used: Medtronic Synchromed, INFUSAID, CADDCPT Code: 36261Procedure: Revision of implanted intra-arterial infusion pumpDescription of Procedure: In this procedure, the infusion pump is replaced if it fails or becomesdamaged during refilling; the catheter is replaced if it becomes occluded.Devices Commonly Used: Medtronic Synchromed, INFUSAID, CADDCPT Code: 36262Procedure: Removal of implanted intra-arterial infusion pumpDescription of Procedure: The entire infusion pump is removed, usually after several weeks or months,depending on the patient’s treatment schedule.Common Therapeutic Indications: Completion of chemotherapy; infected pump or catheterDevices Commonly Used: Medtronic Synchromed, INFUSAID, CADDCPT Code: 36420Procedure: Venipuncture, cutdown; under age 1 yearDescription of Procedure: A vein is surgically exposed (cutdown), and a catheter is inserted through asmall incision in the wall of the vein. When large volumes of fluid are needed, the end (adapter) of anintravenous (IV) tube may be cut off and the IV tubing placed directly into the vein.Coding Tips: CommentsThis is not a central venous line, but a peripheral line that is placed in the arm or leg, most commonly inthe saphenous vein at the ankle.Common Therapeutic Indications: N/ADevices Commonly Used: N/ACPT Codes/Procedures:36555 Insertion of non-tunneled centrally inserted central venous catheter; under 5 years of age
  11. 11. 36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older36575 Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous port or pump, central or peripheral insertion site36580 Replacement, complete, of a non-tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous accessDescription of Procedure: Partially implanted catheters are distinguished from non-tunneled venousaccess devices by the technique required to create the “tunnel,” in which the intracutaneous portion of thecatheter lies. During the placement of a non-tunneled central venous catheter, a short tract is developedas the catheter is advanced from the skin entry site to the point of venous cannulation. During theinsertion of a partially implantable catheter, creating the tunnel requires a specific and separate surgicalstep, not simply a skin incision with tract dilation. Only after the tunnel is developed, can the catheter bepassed between the skin entry site and the point of venous cannulation. The length of the subcutaneousportion of a partially implanted catheter is typically much greater (eg, to reach from below the nipple levelto the subclavicular area) than that of a non-tunneled central venous catheter. (Source: CPT Assistantnewsletter, February1999, page 2).To qualify as a central venous access catheter or device, the tip of the catheter/device must terminate inthe subclavian, brachiocephalic (innominate) or iliac veins, the superior or inferior vena cava, or the rightatrium.The venous access device may be central inserted when the jugular, subclavian, femoral vein or inferiorvena cava is the catheter entry site).For CPT coding, insertion involves the placement of catheter through a newly established venous access.For CPT coding, replacement is performed if an existing central venous access device is removed and anew one placed via a separate venous access site, appropriate codes for both procedure (removal of old,if code exists), and insertion of new device) should be reported.For CPT coding, repair involves fixing a device without replacement of either catheter or port/pump, otherthan pharmacologic or mechanical correction of intracatheter or pericatheter occlusion (see codes 36595or 36596).The work required for removal of a non-tunneled central venous access catheter is considered to beinherent in the evaluation and management visit in which it is performed. (Source: September 2004 CPTAssistant newsletter, AMA, Chicago, IL).There is no distinction between venous access achieved percutaneously versus by cutdown or based oncatheter size.Percutaneous Placement: • The skin is prepped and draped, and a needle (usually 18-gauge, about 3 inches long) with a syringe attached is placed under the lateral third of the clavicle until blood is drawn into the syringe (this confirms that the vein has been entered). A wire is then threaded through the needle, the needle is removed, and a long catheter is threaded over the wire (Seldinger technique), which guides the catheter. The catheter is then inserted through the skin (a “nick”
  12. 12. may be made next to the wire to enlarge the opening) and into a vein of the thoracic cavity (usually the subclavian, internal jugular, femoral or antecubital vein).• The catheter must be placed in the thoracic cavity for several reasons: (1) when the procedure is performed to measure pressure, a more accurate reading is permitted because no valves are located between the end of the catheter and the heart; (2) when chemotherapy is being administered, the relatively large blood flow around the end of the catheter dilutes the drugs, thus minimizing damage to the vein; (3) during hemodialysis, a relatively large catheter is used for better flow (hemodialysis involves pulling blood back across the dialysis coil and reusing it), thus requiring that it be placed in a larger vessel.• Percutaneous placement of a catheter may be performed in a hospital ward, in the intensive care unit or in the operating room, depending on the hospital’s medical policies.• Removal: The suture holding the catheter in place is cut, the catheter is pulled out, and pressure is held on the site.• Do not report codes 36589 or 36590 for removal of a non-tunneled central venous catheters.• An x-ray is usually performed to confirm the position of the catheter. The catheter should not be located in the ventricle or in the atrium because it may erode through the heart. In addition, the catheter tip should not be located so close to the skin that it might come out of the vein.• Catheters used for children are much smaller (4 to 6 cm in length) than those used for adults (7 to 12 cm in length). It is usually more difficult to find the appropriate vein in children when placing a catheter.• Besides their use in chemotherapy, central venous catheters are used for measuring central venous pressure, for guide-wire insertion before insertion of a Swan-Ganz catheter, for parenteral nutrition and for procedures performed on patients with poor peripheral veins. When used intermittently, such as for blood withdrawal, IV fluid administration or medication administration, a venous catheter may be capped with a plug, filled with heparin and may be referred to in the medical record as a heparin lock or hep-lock.• Percutaneous placement of a central venous angiocatheter is sometimes performed for interlipid infusion or hyperalimentation.• Intravenous (parenteral) hyperalimentation is a method of providing total nutrition entirely by the intravenous route. It involves the infusion of a nutrient solution at a constant rate through an indwelling catheter usually placed in the superior vena cava. The procedure is used to provide long-term nutrition to patients whose gastrointestinal function is deranged to the extent that adequate oral intake is prevented for an extended period of time.• In hemodialysis, blood is removed from the body and pumped through a hemodialysis coil, a process that removes toxins from the body when the kidneys are not functioning properly. The “artificial kidney” consists of a synthetic membrane permeable to solutes and water in the blood. Before a patient can receive hemodialysis, access to the circulation system must be obtained to allow a high rate of blood flow through the artificial kidney. In emergency situations, a large catheter, such as a Quinton catheter, may be inserted into either a subclavian or femoral vein. Such catheters are prone to infection and cannot be left in place for a long time.
  13. 13. • Devices Commonly Used: Groshong, Broviac (used commonly in children), Hickmann, Intrasil, Centrasil, PPIC, Corcath, Port-A-Cath, Hemocath, PercuCath, Hydrocath, Arrow multi-lumen, Rauf dual-lumen, triple-lumen, Gambro, Quinton, Cook, Safe-Dwell Plus, and Shiley. Except for the Broviac and Hickmann catheters, all catheters and reservoirs are tunneled just under the skin. Central venous catheters do not have reservoirs. • See code 36597 for repositioning of previous placed central venous catheter under fluoroscopic guidance.Cutdown Placement: • Cutdown refers to the dissection of a vein for insertion of a cannula or needle for administration of intravenous fluids or medication. CPT Assistant newsletter, Oct. 1998, p.10. • The skin is prepped and draped, and an incision is made into the skin to expose one of the veins. The vein is isolated, a small “nick” is made in the vein, and a catheter is inserted through the opening. The catheter is advanced so that the tip is positioned in the superior vena cava. This position is confirmed by either fluoroscopy or chest x-ray. • Removal: A small incision is made along the border of the catheter cuff. The cuff is then dissected free, the catheter tube and cuff are removed, and the skin is closed with two or three sutures. • In the cutdown technique, the vein is exposed and visualized directly, as opposed to the percutaneous technique, in which the vein is entered with a needle, without an incision in the skin. A physician may choose to perform cutdown placement rather than percutaneous placement of a central venous catheter for several reasons: - Multiple percutaneous “sticks” may scar a vessel, and the physician may need to find an alternative vessel that is not as easy to reach. - With very small children, it is more difficult to access their veins percutaneously. • A Hickmann catheter, which has a cuff on it, must be placed via cutdown. A tunnel is made under the skin, and the Hickmann catheter is then put into the vein, so that the site at which the catheter enters the skin is a few inches away from where the catheter enters the vein. The cuff on the catheter is placed in a pocket underneath the skin and acts as a barrier to infection along the catheter “track.” • Devices Commonly Used: Groshong, Broviac, Hickmann, Hydrocath, Arrow multi-lumen, Rauf dual-lumen, triple-lumen, Gambro, Quinton, Shiley, Cook, Port-A-Cath, PPIC, Intrasil, Centrasil, Corcath, Hemocath, PercuCath.CPT Codes/Procedures:36563 Insertion of tunneled centrally inserted central venous access device with subcutaneous pump36576 Repair of central venous access device, with subcutaneous port or pump, central or peripheral insertion site
  14. 14. 36578 Replacement, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site36583 Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous pump, through same venous access36590 Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertionDescription of Procedure: To qualify as a central venous access catheter or device, the tip of thecatheter/device must terminate in the subclavian, brachiocephalix (innominate) or iliac veins, the superioror inferior vena cava, or the right atrium.The venous access device may be central inserted when the jugular, subclavian, femoral vein or inferiorvena cava is the catheter entry site).Insertion of Pump: • A pocket is created under the skin, in the subcutaneous tissues. The pump is inserted into this pocket, and the attached catheter is inserted into a nearby vein and directed into the central veins (similar to a central venous catheter). The site is then closed. A pump may also be placed in the patient’s flank and attached to a catheter that has been inserted into the spinal or epidural space. A lump will remain at the site at which the pump is located. • One type of implantable infusion pump is a disk-shaped device with two chambers, a side port and a catheter. One chamber contains the fluid to be infused, while the second chamber is the charging chamber. It contains a fluorocarbon fluid that expands at body temperature and exerts pressure on the bellows of the pump, thus forcing the fluid to be infused into the catheter. The side port provides access for bolus injections, perfusion studies or catheter flushing. Pump refills and bolus injections are accomplished percutaneously by using a Huber needle to access the self-sealing ports of entry. • Another type of implantable infusion pump is powered by a lithium battery. It consists of a refillable reservoir, an electronic control module and a miniature peristaltic pump. A self- sealing septum permits refill or evacuation of the reservoir with a Huber needle. This type of pump is programmable with a device outside the body, which permits changes in flow rate after the device is implanted. The INFUSAID is an infusion pump that is subcutaneously implanted in a lower abdominal quadrant, with the catheters tunneled to the site of infection. The pump provides a continuous infusion of drugs to the region. • An infusion pump is a device used to provide a continuous infusion of implantable medications (often narcotics) for managing chronic pain. It is also used for administering chemotherapeutic agents, such as 5-fluorouracil or colon or liver cancer. Infusion pumps allow patients to receive some of their treatment at home. The oncologist bases the timing and dosage of chemotherapeutic agents pumped into the patient on the kind of tumor and the chemotherapy administered. When the infusion pump reservoir empties, the patient visits the hospital or ambulatory surgery center on an outpatient basis for a refill. • Devices Commonly Used: Medtronic Synchromed, INFUSAID, CADD
  15. 15. Revision of Pump: • The infusion pump is usually in need of repair due to breakage of the catheter or failure of the pump. A skin incision is made over the pump, and the pump is dissected free. If the pump has failed, it is replaced by a new pump. If the catheter is broken, an attempt to repair it is made or, if this is unsuccessful, a new catheter is inserted. Following replacement of the pump or repair of the catheter, the skin incision is sutured closed. • Devices Commonly Used: Medtronic Synchromed, INFUSAID, CADDRemoval of Pump: • The infusion pump is removed because the pump is infected or the treatment is completed. An incision is made over the pump, which is then dissected free from the surrounding tissues and removed from the pocket. The attached catheter is gently withdrawn, and pressure is applied to the site at which the catheter entered the vein. Following hemostasis, the incision is sutured closed and a dressing applied. • Devices Commonly Used: Medtronic Synchromed, INFUSAID, CADD
  16. 16. CPT Codes/Procedures:36557 Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; under 5 years of age36558 Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older36565 Insertion of tunneled centrally inserted central venous access device, requiring two catheters via two separate venous access sites; without subcutaneous port or pump (eg, Tesio type catheter)36575 Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous port or pump, central or peripheral insertion site36581 Replacement, complete, of a tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access36589 Removal of tunneled central venous catheter, without subcutaneous port or pumpDescription of Procedure: Tunneling is the process of passing the catheter under the skin through asubcutaneous tract. Typically, the dictation will state "the catheter was passed through a subcutaneoustunnel", or "a subcutaneous tunnel was formed". Technically, it is done by having two skin incision sites,then passing a "tunneler" under the skin so that the two holes are connected.To qualify as a central venous access catheter or device, the tip of the catheter/device must terminate inthe subclavian, brachiocephalix (innominate) or iliac veins, the superior or inferior vena cava, or the rightatrium.The venous access device may be central inserted when the jugular, subclavian, femoral vein or inferiorvena cava is the catheter entry site).For CPT coding, insertion involves the placement of catheter through a newly established venous access.For CPT coding, for repair, partial (catheter only) replacement, complete replacement, or removal of bothcatheters (placed from separate venous access sites) of a multi-catheter device, with or withoutsubcutaneous ports/pumps, use the appropriate code describing the service with a frequency of two.For CPT coding of device replacement, if an existing central venous access device is removed and a newone placed via a separate venous access site, appropriate codes for both procedure (removal of old, ifcode exists), and insertion of new device) should be reported.
  17. 17. CPT Codes/Procedures:36560 Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; under 5 years of age36561 Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older36566 Insertion of tunneled centrally inserted central venous access device, requiring two catheters via two separate venous access sites; with subcutaneous port(s)36576 Repair of central venous access device, with subcutaneous port or pump, central or peripheral insertion site36578 Replacement, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site36582 Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous port, through same venous access36590 Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertionDescription of Procedure: The venous access device may be central inserted when the jugular,subclavian, femoral vein or inferior vena cava is the catheter entry site). • Venous access ports are also called vascular access devices (VADs); they are implanted surgically using a local anesthetic. The surgeon creates a subcutaneous pocket to house the portal. The VAD is usually placed under the pectoral muscles or skin in the anterior chest below the clavicle. The catheter is inserted into the desired blood vessel. When the port and catheter are connected, the pocket is closed. • Implantable VADs consist of a reservoir, an inlet septum in the center of the reservoir and a radiopaque outlet catheter (that is placed into a vein). The inlet septum (soft, center part of the VAD) is designed to accept multiple punctures from special types of needles (e.g., Huber) and still maintain its leak-tight integrity. The needle is used to enter the VAD to infuse the medication or chemotherapy. If a standard hypodermic needle is used, the septum will lose its leak-tight integrity. A VAD is not a pump, but the VAD port may be inserted with tubing that is connected to a pump. The entire VAD is self-contained subcutaneously; no part of it is external. • VADs are unlike infusion pumps in that automatic infusion of chemotherapeutic agents is not possible. The VAD may be used without the subcutaneous reservoir. Patients with VADs often visit the hospital or ASC at least once a month for chemotherapy, although the timing may vary depending upon the kind of tumor being treated. • Completely implanted devices: includes a subcutaneous reservoir with a self-sealing septum, through which the catheter is permanently accessed by a non-coring needle (eg, Huber, Angiocath). All portions of a completely implanted device are located beneath the skin. • Partially implanted devices: such as Hickman and Broviac include a visible external site(s) remote from the venous entry site. External injection/infusion cap(s) lead to the device’s one or more lumen(s). Partially implanted devices do not have subcutaneous reservoirs. In
  18. 18. addition to the external access site(s), partially implanted devices travel beneath the skin before entering the vein. Partially implanted catheters are distinguished from non-tunneled venous access devices by the technique required to create the “tunnel,” in which the intracutaneous portion of the catheter lies. During the placement of a non-tunneled central venous catheter a short tract is developed as the catheter is advanced from the skin entry site to the point of venous cannulation. During the insertion of a partially implantable catheter, creating the tunnel requires a specific and separate surgical step, not simply a skin incision with tract dilation. Only after the tunnel is developed, can the catheter be passed between the skin entry site and the point of venous cannulation. The length of the subcutaneous portion of a partially implanted catheter is typically much greater (eg, to reach from below the nipple level to the subclavicular area) than that of a non-tunneled central venous catheter. (Source: CPT Assistant newsletter, February1999, page 2).• VADs are catheters that provide prolonged vascular access for chemotherapy, intravenous fluids, medications or the withdrawal of blood for blood sampling. The device typically is implanted in patients who require long-term access for chemotherapy or for nutritional purposes. A manufacturer’s identification label on the medical record will verify that a venous access port and not a central venous catheter (codes 36488–36491) was inserted. The labels usually contain the following: name of manufacturer, name of device, patient name, product code, lot number, implant site, implant date and implanting surgeon.• The catheter may need to be replaced if it breaks or detaches from the portal of the VAD. An x-ray is used to determine these situations. An incision is made over either the VAD, in the case of a detached catheter, or over the appropriate part of the catheter, if the catheter is broken. The discontinuity is then repaired, and the skin incision is closed with sutures.• The VAD maybe removed because it is infected or the treatment is completed. An incision is made over the VAD. The VAD is then dissected free from the surrounding tissues and removed from the pocket. The attached catheter is gently withdrawn, and pressure is applied to the site at which the catheter entered the vein. Following hemostasis, the incision is sutured closed and a dressing applied.• The venous access device may be central inserted when the jugular, subclavian, femoral vein or inferior vena cava is the catheter entry site).• For CPT coding, insertion involves the placement of catheter through a newly established venous access.• For CPT coding, for repair, partial (catheter only) replacement, complete replacement, or removal of both catheters (placed from separate venous access sites) of a multi-catheter device, with or without subcutaneous ports/pumps, use the appropriate code describing the service with a frequency of two.• For CPT coding of device replacement, if an existing central venous access device is removed and a new one placed via a separate venous access site, appropriate codes for both procedure (removal of old, if code exists), and insertion of new device) should be reported.• Use code 96530 for the refilling and maintenance of an implantable pump or reservoir.• Devices Commonly Used: Norport, Medtronic, MicroPort, Q-Port, Infuse-a-Port, Dual Port, Groshong, MacroPort, Button Port, Port-A-Cath, LifePort
  19. 19. CPT Codes/Procedures:36568 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; under 5 years of age36569 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; age 5 years or older36570 Insertion of peripherally inserted central venous access device, with subcutaneous port; under 5 years of age36571 Insertion of peripherally inserted central venous access device, with subcutaneous port; age 5 years or older36575 Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous port or pump, central or peripheral insertion site36576 Repair of central venous access device, with subcutaneous port or pump, central or peripheral insertion site36578 Replacement, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site36584 Replacement, complete, of a peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, through same venous access36585 Replacement, complete, of a peripherally inserted central venous access device, with subcutaneous port, through same venous access36590 Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertionDescription of Procedure: To qualify as a central venous access catheter or device, the tip of thecatheter/device must terminate in the subclavian, brachiocephalix (innominate) or iliac veins, the superioror inferior vena cava, or the right atrium.The venous access device may be peripherally inserted (eg, basilic or cephalic vein).For CPT coding, insertion involves the placement of catheter through a newly established venous access.For CPT coding, replacement is performed if an existing central venous access device is removed and anew one placed via a separate venous access site, appropriate codes for both procedure (removal of old,if code exists), and insertion of new device) should be reported.Coding Tip: • A midline catheter is merely a shorter length version, peripherally inserted, central venous catheter. Therefore, codes 36568-36569 would be the most appropriate codes to report for a PICC (midline catheter) line. These codes are selected based upon the specific age described in the code descriptor. (Source: October 2004 CPT Assistant newsletter, AMA, Chicago, IL).
  20. 20. CPT Codes/Procedures:36595 Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venous device via separate venous access36596 Mechanical removal of intraluminal (intracatheter) obstructive material from central venous device through device lumenDescription of Procedure: Advances in device technology have allowed for long-term venous accessfor patients undergoing chemotherapy, dialysis, etc. Occasionally, fibrin will collect at the distal end ofthese devices or within the lumen. As well, thrombus may form inside the device, thus creating anobstruction. If an injection of a small amount of a thrombolytic agent is unsuccessful, other interventionswill often allow continued use of the existing device rather than removing and introducing a new device.This is of far less potential risk and morbidity to the patient. Treatment options include stripping the fibrinsheath from/about the existing catheter by use of either a transcatheter snare or balloon under imagingguidance, or alternatively, clearing the intraluminal obstructive material with a guidewire, brush, or othermechanical device under imaging guidance.Coding Tip: • Codes 36595 and 36596 have associated radiological supervision and interpretation codes (75901 for 36595 and 75902 and 36596), which should be separately coded to describe appropriate imaging guidance and interpretation when such services are performed. It should also be noted that when these codes are used, related vascular catheterization codes 36010-36012 should be separately reported to describe these related component services when performed. (Source: December 2004 CPT Assistant newsletter, AMA, Chicago, IL).CPT Code: 36550Procedure: Declotting by thrombolytic agent of implanted vascular access device or catheterDescription of Procedure: A thrombolytic agent which is introduced through a syringe and then slowlyinstilled into the device or catheter.Coding Tips:• Use this code to report the declotting of partially or completely implanted devices and catheters.• Do not use this code for routine flushing of vascular access devices with saline or heparin (thistype of flushing is considered inclusive to chemotherapy services and is not reported separately.)CPT Codes/Procedures:36568 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; under 5 years of age36569 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; age 5 years or older
  21. 21. Description of Procedure:The term midline catheter is used by many different individuals to describe different types of peripherallines, some terminating in the chest and some in a peripheral vein. More important than the title given tocatheter is the exact anatomic position of the catheter, which can only be determined from careful reviewof a well-dictated report.Depending upon patient’s age, this service should be coded as 36568 (under 5 years of age) or 36569(age 5 or older). Source: May 2005 CPT Assistant newsletter, AMA, Chicago, IL.CPT Code: 36598Procedure: Contrast injection(s) for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation and reportDescription of Procedure: The physician performs a quick physical inspection of the catheter site. Ifthe catheter is not dislodged or kinked, the physician exposes and preps the external port of the catheterin sterile fashion. Fluoroscopic evaluation of the catheter is performed by the physician, confirming thatthe tip of the catheter lies in the central vein as intended and has not migrated into the heart or beenpulled back into a peripheral vein or out of the vein. Fluoroscopy also determines if the catheter has beenfractured or kinked. The physician aspirates the catheter and indwelling anticoagulant is discarded ifpossible. Contrast is injected by the physician with imaging of the catheter tip and the vein where thecatheter tip and the vein where the catheter tip is positioned. If necessary, imaging is performed along thecourse of the catheter to determine if there is a leak in the catheter. The catheter is flushed with salineand may be locked with anticoagulant solution. Source: CPT Changes 2006: An Insider’s View, AMA,Chicago, IL.Coding Tips • Once imaging is completed, any procedures that are done to try to restore function of the catheter, if necessary, are coded separately. Source: CPT Changes 2006: An Insider’s View, AMA, Chicago, IL. • Do not report 36598 in conjunction with 76000. • Do not report 36598 in conjunction with 36595, 36596. • For complete diagnostic studies, see 75820, 75825, 7582 (only for those circumstances where these structures required a more extensive study).CPT Code: 36600Procedure: Arterial puncture, withdrawal of blood for diagnosisDescription of Procedure: In order to draw blood for arterial blood gas analysis, a single, one-timeneedle “stick” is performed to an artery, without a device being left in the vessel.Coding Tips: Comments
  22. 22. This procedure is similar to a venipuncture, except that it involves an artery.Common Therapeutic Indications: N/ADevices Commonly Used: N/ACPT Code: 36620Procedure: Arterial catheterization or cannulation for sampling, monitoring or transfusion(separate procedure); percutaneousDescription of Procedure: Catheterization: A 2- or 3-inch catheter is placed percutaneously over aneedle into the artery (usually a brachial, femoral, radial, temporal or posteriotibial artery). The cathetermay be left in place for days (sometimes up to two weeks).Cannulation: The same type of catheter that is inserted into a vein (intravenous catheter with a needleenclosed by a sheath) is used. The artery is “stuck” with the needle tip; when blood comes back throughthe needle, the catheter is slid off the needle into the artery and left there. The needle is removed, andthe catheter is connected to the transducer or other device.Common Therapeutic Indications: The arterial catheter is used for monitoring arterial pressures andwithdrawing blood samples for lab studies.Devices Commonly Used: N/ACPT Code: 36625Procedure: Arterial catheterization or cannulation for sampling, monitoring or transfusion(separate procedure); cutdownDescription of Procedure: A skin incision is made over a peripheral artery (usually radial or dorsalispedis), and the artery is dissected free. A 20-gauge needle enclosed in a sheath (catheter) is inserteddirectly into the artery; the catheter is then slid off the needle into the artery and the needle is withdrawn.The catheter is then connected to a transducer for pressure measurement. The skin incision is suturedclosed.Common Therapeutic Indications: N/ADevices Commonly Used: N/ACPT Code: 36640Procedure: Arterial catheterization for prolonged infusion therapy (chemotherapy), cutdownDescription of Procedure: Placement of the arterial catheter for prolonged infusion therapy may beperformed in one of two ways. (1) A peripheral artery is dissected free and a catheter is inserted into theartery and threaded, under fluoroscopic or angiographic control, to the site of the tumor. (2) Anabdominal incision is made (for a hepatic tumor); the hepatic artery is isolated and the catheter is inserted
  23. 23. directly into the artery near the liver. The catheter is then brought out through the skin and the incisionclosed.Common Therapeutic Indications: Arterial catheterization delivers chemotherapeutic agents directlyinto the blood supply of the tumor in higher doses than the patient normally can tolerate. This methodtypically is used with hepatic tumors or metastases to the liver.Devices Commonly Used: N/ACPT Code: 36800Procedure: Insertion of cannula for hemodialysis, other purpose (separate procedure); vein toveinDescription of Procedure: A cannula (which is a hollow tube) is placed between the two ends of a veinthat has been divided (cut in half). The incision is then closed. No portion of the cannula or vein isexposed outside the skin. This allows venous access by “sticking” the cannula rather than the vein.Common Therapeutic Indications: N/ADevices Commonly Used: N/ACPT Code: 36810Procedure: The insertion of cannula Insertion of cannula for hemodialysis, other purpose(separate procedure); arteriovenous, external (Scribner type)Description of Procedure: A cannula is placed in the artery and brought out to the skin; the other end ofthe cannula is placed into a vein (most common sites are near brachial artery and brachial vein). Thisallows the cannula portion of the catheter to lie externally on the skin, and the external portion is availablefor access.Coding Tips: CommentsAccording to the American Medical Association “code 36815 is reported when a Scribner-type shunt isrevised (i.e., when the shunt fails and the vessel tip must be placed in a different vessel).” The bulk of thecannula is left in the same site and the tip is connected into another vessel.Common Therapeutic Indications: This procedure may be used if the patient doesn’t have veins fordirect access or is extremely thin and there is inadequate subcutaneous tissue to appropriately cover acannula/shunt. The Scribner-type shunt is a silastic shunt that fits over the vessel tip and is tunneled to askin exit site; then it is connected to its mate by another shunt Teflon tube, which can be removed(opened) to connect to the dialysis tubing.Devices Commonly Used: ScribnerCPT Code: 36815Procedure: Insertion of cannula for hemodialysis, other purpose (separate procedure);arteriovenous, external revision, or closureDescription of Procedure: A revision of an external venous-to-venous cannula typically is performed tocorrect infection of the cannula or occlusion by a clot. This is accomplished by replacing the cannula,
  24. 24. resecting the veins or removing the clot. If these procedures are not successful or indicated, the cannulais removed and the veins ligated.Common Therapeutic Indications: N/ADevices Commonly Used: ScribnerCPT Code:36818Procedure: Arteriovenous anastomosis, open; by upper arm cephalic vein transpositionDescription of Procedure:This procedure requires two upper arm incisions, one medial over the brachial artery, the other lateral toexpose the vein. A tunnel is created between the incisions, and complete dissection of a substantialportion of the cephalic vein is required to allow it to be moved to a more superficial location and pulledthrough the tunnel for anastomoses with the brachial artery on the medial aspect of the upper arm.Under unusual situations a patient might undergo 36818 on one upper extremity and a proceduredescribed by code 36819 (basilica vein transposition), 36820 (forearm vein transposition), 36821 (opendirect arteriovenous anastomosis) or 36830 (nonautogenous graft arteriovenous fistula) on thecontralateral upper extremity. This circumstance would be reported by adding modifier 59 for the secondside (procedure). One indication for the unusual pair of simultaneous operations would be in a proceduresetting in which hemodialysis access is needed in the immediate future, but caregivers hope to avoid acatheter. A permanent native fistula could be placed in one arm (36818) while a prosthetic hemodialysisgraft is placed in other arm (36830). The shorter-lived prosthetic graft would then be immediatelyavailable for hemodialysis (useable in less than a week if necessary) while allowing 6-8 weeks for thenative fistula to mature.Code 36818 differs from existing code 36819 in that the procedure described by code 36819 consists ofthe basilic vein transposition for brachiobasilic anastomoses.Code 36818 differs from existing code 36820 in that the procedure described by code 36820 consists offorearm vein transposition performed in the lower arm between the elbow and the wrist.Code 36818 differs from existing code 36830 in that the procedure described by code 36830 is the mostcommonly performed hemodialysis access operation, and is used to report placement of a syntheticsubcutaneous tube graft in which one end is anastomosed to the brachial artery and the other to a largevein. This is most often performed when patients do not have large, visible wrist veins for performance ofa native Cimino fistula (36821).Coding Tips: • Do not report 36818 in conjunction with 36819, 36820, 36821, 36830 during a unilateral upper extremity procedures. For bilateral upper extremity open arteriovenous anastomoses performed at the same operative session, use modifier 50 or 59 as appropriate) .
  25. 25. Common Therapeutic Indications:This approach is often performed in patients with large or obese arms.CPT Code: 36819Procedure: Arteriovenous anastomosis, open; basilic vein transpositionDescription of Procedure: Basilic vein transposition entails much more work than placement of anonautogenous upper arm graft, since it requires complete dissection of the entire basilic vein from theantecubital crease up to the axilla. The basilic vein is much deeper in the soft tissue and almost alwayshas overlying nerves that must be preserved. This procedure requires complete, longitudinal veindissection for the entire length of the upper arm, creation of a tunnel, and relocation of the vein into thenew, more superficial location.Coding Tip: • Do not report 36819 in conjunction with 36818, 36820, 36821, 36830 during a unilateral upper extremity procedure. For bilateral upper extremity open arteriovenous anastomoses performed at the same operative session, use modifier 50 or 59 as appropriate)CPT Code: 36820Procedure: Arteriovenous anastomosis, open; by forearm vein transpositionDescription of Procedure: Code 36820 describes a procedure involving dissection of a long segment ofvein from its site and relocating it to a more superficial or easily accessible position for the purpose ofhemodialysis.CPT Code: 36821Procedure: Arteriovenous anastomosis; open direct, any site (e.g., Cimino type) (separateprocedure)Description of Procedure: The vein is connected directly to the artery without an interposing graft (twoadjacent vessels are connected). This is usually possible when the artery and vein are very close to eachother.Coding Tips: N/ACommon Therapeutic Indications: N/ADevices Commonly Used: N/ACPT Code: 36823
  26. 26. Procedure: Insertion of arterial and venous cannula(s) for isolated extracorporeal circulation includingregional chemotherapy perfusion to an extremity, with or without hyperthermia, with removal of cannula(s)and repair of arteriotomy venotomy sitesDescription of Procedure: This procedure includes calculation and administration of the chemotherapyagent injected directly into the parfusate. Code 36823 is intended to describe placement of venoarterialcannulation for chemotherapy perfusion (supported by a membrane oxygenate/perfusion device) to anisolated region of an extremity to treat a neoplastic process.Coding Tips: • 36823 Includes chemotherapy perfusion supported by a membrane oxygenator/perfusion pump. • Do not report 96408-96425 in conjunction with 36823CPT Code: 36825Procedure: Creation of arteriovenous fistula by other than direct arteriovenous anastomosis(separate procedure); autogenous graftDescription of Procedure: Arteriovenous anastomosis between two vessels using an interposing graftmade of the patient’s natural vein (autogenous). For chronic hemodialysis, vascular access usuallyrequires the surgical construction of an arteriovenous (A-V) fistula between the patient’s artery and vein,most often in the forearm. The fistula “matures” in four to six weeks, and increased blood flow causes thevenous site to become enlarged.Coding Tips: CommentsAlthough less problematic than external catheters, both fistulas and grafts are prone to infection andblood clotting.CPT Code: 36830Procedure: Creation of arteriovenous fistula by other than direct arteriovenous anastomosis(separate procedure); nonautogenous graftDescription of Procedure: Arteriovenous anastomosis between two vessels using a synthetic materialas an interposing graft (nonautogenous). A nonautogenous A-V fistula/graft is a tube made from Gortex,polytetrafluoroethylene (PTFE) or similar biocompatible material. The tube is surgically tunneled underthe skin in a loop that connects an artery to a vein.Coding Tips: Comments* See code 36825.* See codes 35501–35683 for creation of bypass grafts.Common Therapeutic Indications: The artery and vein are far enough apart that they cannot bedirectly anastomosed, so a graft material must be used to connect them.Devices Commonly Used: GortexCPT Code: 36831Procedure: Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous dialysis graft (separate procedure)
  27. 27. Description of Procedure: In these procedures, when arteriovenous fistulae placed for dialysis (madeof autogenous vein or non-autogenous prosthetic graft material) thrombose, thrombectomy proceduresare needed in order to dialysis (made of autogenous vein or non-autogenous prosthetic graft material)thrombose, thrombectomy procedures are needed in order to maintain hemodialysis. After thethrombectomy, revision of the graft may or may not be required. The nomenclature of code 36831delineates thrombectomy where graft revision is not performed.Thrombectomy: The fistula/graft is opened, a catheter (e.g., Fogarty) is inserted into the fistula and theclots are extracted.The most common site for these arteriovenous dialysis grafts is the forearm or upper arm. At operation,circumferential exposure of the venous outflow end of the graft is obtained by dissection through typicallyscarred tissue. Systemic anti-coagulation is administered, and vascular occluding clamps are placed. Anincision is made in the hood of the graft, and a thrombus filled lumen is encountered. Fogarty balloonthrombectomy catheters are passed repeatedly in the proximal and distal directions until forceful arterialinflow and adequate venous backbleeding are obtained. The graft opening is closed using fine vascularsuture, often under ocular loupe magnification. An operative angiogram is frequently obtained todetermine the etiology of graft failure by injecting contrast material while making a single x-ray exposureor using digital subtraction fluoroscopy.The most common pathology found in this situation is severe intimal hyperplasia in the outflow vein, butoccasionally, no contributory pathology is found. This is likely to be the case if the patient has suffered arecent episode of hypotension. If the angiogram reveals no identifiable problems, blood flow through thedialysis graft and to the hand beyond the graft is evaluated once more for adequacy. If satisfactory, thewounds are closed in layers.Coding Tips: With exception of the unlikely circumstances that a patient has two different dialysis graftsthat the surgeon operated on during the same surgical event, codes 36831 , 36832, and 36833 aregenerally not reported together (i.e., they are not used to describe procedures performed on the samegraft). If two different dialysis grafts are being addressed, then the appropriate codes for the procedureperformed should be used with the modifier –59 appended to the second procedure performed to identifyit as a distinct procedural service.CPT Code: 36832Procedure: Revision, open, arteriovenous fistula; without thrombectomy, autogenous ornonautogenous dialysis graft (separate procedure)Description of Procedure: The most common site for these arteriovenous dialysis grafts is in theforearm or upper arm. The pathology usually encountered is venous hyperplasia along the outflow trackof the graft, causing a severe stenosis, reduction of blood flow through the graft, ineffective dialysis, andeventual graft thrombosis, if treatment is not undertaken. At operation, circumferential exposure of thevenous outflow end of the graft and adjacent outflow veins is obtained by dissection through typicallyscarred tissue. Systemic anti-coagulation is administered, and vascular occluding clamps are placed. Anincision is made in the hood of the graft at the anastomosis and extended across the venous stenosisuntil vein of normal caliber is encountered. A long synthetic patch is sewn as a “patch angioplasty” alongthe length of the arteriotomy, often using ocular loupe magnification. The graft and outflow vein areflushed with blood to remove loose debris and air, then blood flow is re-established, and hemostasisachieved. Blood flow through the dialysis graft and to the hand beyond the graft is evaluated foradequacy. Once satisfactory flow is obtained, the wounds are closed in layers.Revision: The fistula/graft site is opened in order to straighten a kink or remove a clot and re-anastomose the graft.
  28. 28. • According to the AMA, assign code 36832 if an angioplasty is performed on an A-V fistula.Blood flow through the dialysis graft and to the hand beyond the graft is evaluated for adequacy. Oncesatisfactory flow is obtained, the wounds are closed in layers.Coding Tips: CommentsA clotted A-V access site often can be salvaged by surgical thrombectomy; many infections can be curedwith antibiotics. In some cases, however, infection or thrombosis may necessitate construction of newvascular access.• See codes 34001–34490 for excision of an acquired traumatic thrombus or congenital thrombusof an artery or vein.• See codes 35180–35190 for repair of a congenital or acquired traumatic arteriovenous fistula.• See codes 35201–35286 for repair of a blood vessel, other than for fistula.• See codes 35301–35381 for thromboendarterectomy of a vein or artery.• Do not assign code 36145 (introduction of needle or intracatheter; arteriovenous shunt created fordialysis [cannula, fistula or graft]) for creation or revision of an A-V graft/cannula/ fistula. This code isassigned only when an angiography of an A-V shunt (shuntogram) is performed; it describes thesurgical/technical component of the procedure. Code 75790 should be assigned to report theprofessional component of this interventional radiology (i.e., shuntogram) procedure.• With the exception of the unlikely circumstances that a patient has two different dialysis graftsthat the surgeon operated on during the same surgical event, codes 36831, 36832, and 36833 aregenerally not reported together (i.e., they are not used to describe procedures performed on the samegraft). If two different dialysis grafts are being addressed, then the appropriate codes for the procedureperformed should be used with the modifier –59 appended to the second procedure performed to identifyit as a distinct procedural service.Common Therapeutic Indications: The A-V fistula/graft is kinked, or there is a possibility that thebody’s endothelium will “grow” into the fistula/graft and act as a thrombus, which will cause poor bloodflow in the fistula/graft. Another indication is that the site of the fistula/graft may begin to “scar down” andbecome stenosed; this reduces the blood flow. Other problems include failure of maturation(approximately four to six weeks is needed for the vein to respond to increased flow by enlargement andmural thickening; shunts formed by grafts can be used earlier, and no maturation is necessary). Inaddition, infection, pseudoaneurysm formation and vascular “steal” may develop. Vascular steal involvesthe diversion of blood flow from the distal extremity through a shunt, which causes pain and ischemia.Vascular steal commonly results from a shunt/fistula that is too large. (The incidence of vascular steal isdecreasing due to the introduction of tapered grafts.)Devices Commonly Used: Fogarty catheter (for thrombectomy)CPT Code: 36833Procedure: Revision, open, arteriovenous fistula; with thrombectomy, autogenous ornonautogenous dialysis graft dialysis graft (separate procedure)
  29. 29. Description of Procedure: For those instances wherein both arteriovenous fistula revision andthrombectomy is performed, code 36833 reported to more accurately report the additional physician workinvolved.The most common site for these arteriovenous dialysis grafts is in the forearm or upper arm. Anoperation, circumferential exposure of the venous outflow end of the graft is obtained by dissectionthrough typically scarred tissue. Systemic anticoagulation is administered, and vascular occluding clampsare placed. An incision is made in the hood for the graft, and a thrombus-filled lumen is encountered.Fogarty balloon thrombectomy catheters are passed repeatedly in the proximal and distal directions untilforceful arterial inflow and adequate venous backbleeding are obtained. The graft opening is closedusing fine vascular suture under ocular loupe magnification. An operative angiogram is obtained todetermine the etiology of graft failure by injecting contrast material while making a single x-ray exposureor using digital subtraction fluoroscopy.The most common pathology found in this situation is severe intimal hyperplasia in the outflow vein,although arterial stenosis or failure of the conduit itself are other typical findings. If venous outflowhyperplasia if found, vascular occluding clamps are replaced, the distal-most portion of the dialysis graft isopened, and the incision is carried across the vein stenosis and extended until normal caliber vein isencountered. A long synthetic patch is sewn as a “patch angioplasty” along the length of the arteriotomy,using ocular loupe magnification. The graft and outflow vein are flushed with blood to remove loosedebris and air, then blood flow is re-established, and hemostasis achieved. Blood flow through thedialysis graft and to the hand behind the graft is evaluated for adequacy. Once satisfactory flow isobtained, the wounds are closed in layers. If other causes of graft thrombosis are found, they are dealtwith as required.Thrombectomy: The fistula/graft is opened, a catheter (e.g., Fogarty) is inserted into the fistula and theclots are extracted.Revision: The fistula/graft site is opened in order to straighten a kink or remove a clot and re-anastomose the graft.Coding Tips: With the exception of the unlikely circumstances that a patient has two different dialysisgrafts that the surgeon operated on during the same surgical event, codes 36831, 36832, and 36833 aregenerally not reported together (i.e., they are not used to describe procedures performed on the samegraft). If two different dialysis grafts are being addressed, then the appropriate codes for the procedureperformed should be used with the modifier If two different dialysis grafts are being addressed, then theappropriate codes for the procedure performed should be used with the modifier 59 appended to thesecond procedure performed to identify it as a distinct procedural service.CPT Code: 36834Procedure: Plastic repair of arteriovenous aneurysm (separate procedure)Description of Procedure: An aneurysm results when a weakness develops in the wall of a bloodvessel due to trauma or repeated punctures (needle sticks). Significant dilation may cause a radial arteryaneurysm to fistulize to a vein located next to it. The dilation or weak vessel may be resected.Coding Tips: CommentsIf there is no dilation, and there is a small hole or communication between the artery and the vein, aligation of the fistula or resection of the vessels is necessitated.Coding Tip: Assign this code for the repair of an aneurysm in a direct anastomosis arteriovenous fistula(i.e., a fistula without an interposing graft). Assign code 36832 or 36832 for the repair of an aneurysm inan arteriovenous fistula with an interposing graft.
  30. 30. Common Therapeutic Indications: N/ADevices Commonly Used: N/ACPT Code: 36838Procedure: Distal revascularization and interval ligation (DRIL), upper extremity hemodialysisaccess (steal syndrome)Description of Procedure: DRIL does not involve any surgical manipulation of the access itself. TheDRIL procedure addresses this issue as a two-step procedure. The surgeon begins by placing a bypassgraft in the involved arm. The proximal anastomosis of the bypass is placed closer to the axilla than thedialysis access origin. The distal anastomosis of this bypass extends onto the forearm, beyond thedialysis access. This part is the “distal revascularization,” and in essence it allows diversion of a strongblood flow stream around the dialysis access without altering that access. Once completed, the secondstep, “interval ligation,” consists of tying off the brachial artery at a site between the dialysis access andthe distal anastomosis of the new bypass. This step prevents blood flow traveling through the newbypass to the forearm from turning retrograde in the brachial artery and entering the dialysis access. Inessence, the DRIL works by allowing arterial blood flow coming from the heart to enter the DRIL bypassbefore it reaches the origin of the hemodialysis access. The DRIL forces the arm’s blood flow to beshared between the dialysis access and the hand.The goal of DRIL is to save the hand and preserve the dialysis access and to not waste an access site.To simple ligate or disconnect the dialysis access will return the anatomy to its native status, but it willleave the patient without permanent hemodialysis access. If the steal syndrome occurs in one upperextremity, it is likely that it will occur on the opposite side as well, due to the vascular anatomy of theindividual. Therefore, ligation is not considered a major clinical victory.Coding Tips/Comments:Common Therapeutic Indications: Distal revascularization and interval ligation (DRIL) is a procedureperformed for the treatment of steal syndrome, a condition that occurs in a small portion of patients whohave undergone upper extremity hemodialysis access operations, to provide reliable permanentindwelling needle access for long-term hemodialysis. A small percentage of patients who haveundergone the operation to create the hemodialysis access develop ischemic hand pain postoperatively.In these cases, the patient’s new hemodialysis access takes virtually all of the arm’s blood flow, leavingthe hand starving for blood and oxygen.Devices Commonly Used: N/A.CPT Code: 36860Procedure: External cannula declotting (separate procedure); without balloon catheterDescription of Procedure: After the cannula is opened, it may be squeezed or “milked” with the fingersto remove the clot; or the cannula may be flushed to remove the clot. This technique may be used oninternal or external cannulas; is a type of triple-lumen Ligation - Occlusion of the lumen of a vessel byapplication of a suture ligature that cuts off the flow in the vessel and causes it to clot; central line having“external” ports. These do not require “open” incisional techniques to remove the clots.Code 36860 classifies A “nick” is made in or proximal to the cannula; the balloon (Fogarty) catheter isinserted into the cannula through the nick, blown up and then pulled back to pull out or extract the clot;thrombectomy performed on external types of dialysis devices (e.g., Scribner, Hickman, Quentin). Thisrevision differentiates between open thrombectomy procedures reported by the new code 36831.
  31. 31. Coding Tips: CommentsClot: Coagulation of blood within the cannula.Thrombus: An organized clot is present in the A-V fistula/graft for a long period of time and that mayhave embolized from another site.* Codes 36860 and 36861 contain the phrase “external,” thus precluding the reporting of these codes forpercutaneous thrombectomy because dialysis grafts/fistulae are entirely subcutaneous. Source: CPTChanges 2001: An Insider’s View, AMA.Common Therapeutic Indications: N/ADevices Commonly Used: N/ACPT Code: 36861Procedure: External cannula declotting (separate procedure); with balloon catheterDescription of Procedure: A “nick” is made in or proximal to the cannula; the balloon (Fogarty) catheteris inserted into the cannula through the nick, blown up and then pulled back to pull out or extract the clot.Coding Tips: • If the operative report describes A-V fistula/graft revision and/or thrombectomy, see code 36831– 36833. • Codes 36860 and 36861 contain the phrase “external,” thus precluding the reporting of these codes for percutaneous thrombectomy because dialysis grafts/fistulae are entirely subcutaneous. Source: CPT Changes 2001: An Insider’s View, AMA.Common Therapeutic Indications: N/ADevices Commonly Used: N/ACPT Code: 36870Procedure: Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenousgraft (includes mechanical thrombus extraction and intra-graft thrombolysis)Description of Procedure: The thrombus may be removed from the graft in a variety of methods.Heparin may be given systemically; thrombolytic drugs may be given into the graft, either as a bolus, asan infusion, or using a pulsed-spray technique. A limited dose of thrombolytic agent may be instilled intothe thrombus for initiation of thrombolysis. The thrombus may also be mechanically removed with avariety of specially-designed devices or with Fogarty-type angioplasty-type balloons. The thrombus isthen macerated and the shunt cleared.Once the maneuvers to remove the thrombus have been completed, repeat fistulography is performed toverify flow and to evaluate the graft for underlying problems which may have caused the hemodynamiclesion. Any hemodynamic lesions found are treated (e.g., with balloon angioplasty or occasionally withstent placement, both of which are coded separately from the declotting procedure itself).
  32. 32. Code 36870 is designed to cover any of these methods or combinations of these methods, and is usedonly to describe the actual procedure of removing thrombus from the access and restoring flow. Whenthese accesses thrombose, most develop what is termed an “arterial plug,” or a small densely fibrotic clot,at the arterial anastomosis, that typically will not dissolve and which usually sticks in the graft, narrowingor occluding the arterial inflow. This code also describes removal of this portion of the thrombus, whichusually requires an additional step for removal separate from the rest of the procedure to declot the graft.Pharmaceutical thrombolysis: the thrombosed graft is typically accessed using one or two catheters orintracathers to allow instillation of a thrombolytic drug directly into the thrombus. The drug may bedelivered in a bolus, as “pulse spray” with manual bursts of drug delivered through a catheter, or as aninfusion through a catheter. Pharmaceutical thrombolysis typically dissolves the majority of the thrombus.The rest is treated using mechanical means such as balloon inflation to compress or dislodge thethrombus. The arterial plug is typically removed by partially inflating a balloon at the arterial anastomosisand pulling the balloon into the graft, which pulls the arterial plug into the graft. The plug is then furthertreated with maceration or dislodgement from the graft.Mechanical thrombolysis: the thrombosed graft is typically accessed with direct puncture. Sheaths areplaced into the graft to facilitate introduction of the thrombectomy device and the device is activated andpassed through the thrombus until the thrombus is macerated and/or removed. Mechanical thrombolysismay also be accomplished without use of devices made specifically for this purpose. Small Fogarty-typeballoons are another example of a type of device that may be used for this purpose.Coding Tips:• Do not report 36550 in conjunction with code 36870. 36550 classifies thrombolytic agent declotting ofimplanted VAD or catheter.* Punctures into the graft to allow access to both anastomoses is coded with 36145 and should be codedtwice (e.g. 36145, 36145-59) if two separate punctures are performed.* Report 75790 for diagnostic fistulogram imaging.• Assign 35476 and 75978 for a venous anastomotic stenosis treated with balloon angioplasty to restore patency and flow.• Assign a single venous angioplasty code, if there is treatment of multiple venous stenoses clumped in the same vessel.• If a separate vessel from the initially treated stenotic vessel is involved, such as the subclavian vein, percutaneous transluminal angioplasty (PTA) of that lesion should be coded as a second venous angioplasty (i.e., 35476, 75978, 35476-59, 75978-59). The modifier –59 is used to delineate the treatment of a separate vessel.• Assign code 37205 and 75960 for stent placement which may be required in some cases to salvage a failing access or to treat an acute vessel rupture following venous PTA.• Arterial stenosis, either at the arterial anastomosis or in the inflow vessels, is not commonly found, but may be present and may be the flow-limiting cause of acute thrombosis of the graft. Angioplasty of these types of lesions would be coded with braciocephalic angioplasty codes 35475 and 75962 in

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