2. Venous Stenosis Associated with Tunneled Dialysis Catheter Placement and Exchange ASDIN Coding University 1

3. Stenosis With Catheter Placement In some cases, stenosis is suspected after the target vein has been cannulated when difficult is encountered in passing a guidewire The lesion can be confirmed by angiography In some of these cases it is possible to salvage the site by doing a venous angioplasty 2

4. Coding of Procedure This procedure should be coded as a venous angioplasty The code for venous angioplasty is 35476 The descriptor for this code is – transluminal balloon angioplasty, venous Code 75978 should also be used for the radiological supervision and interpretation 3

5. Angiogram In performing this procedure, it may be necessary to do one or several angiograms These should not be coded because +77001 (fluoroscopic guidance) that is used for catheter placement bundles all fluoroscopic examinations 4

6. Use of +77001 - 59 When a diagnostic S&I code is used in association with a therapeutic S&I code, a -59 modifier should be attached to the former If a venous angioplasty is performed in conjunction with a tunneled catheter placement, the diagnostic code +77001 (fluoroscopic guidance) should have a 59 modifier added 5

7. With Catheter Exchange Venous stenosis complicating catheter exchange may be detected in 2 ways – When difficult is encountered inserting the new catheter – In the process of treating a fibrin sheath In both instances, it is not practical to perform an angiogram to document stenosis Stenosis is documented by a defect in balloon 6

8. Difficulty Inserting New Catheter When difficult is encountered in inserting the new catheter, is frequently due to stenosis In most instances an angioplasty balloon is inserted, passed to the spot and a dilatation is performed The presence of stenosis is documented by the defect in the balloon 7

9. Coding This cases should be coded with 35476/75978 The appearance of the balloon should be used to judge % stenosis compared to what the normal vein should be It should be 50% or greater to warrant the code 8

10. While Treating a Fibrin Sheath When a catheter exchange is being done for dysfunction, the case should be checked for a fibrin sheath If present, removal is indicated This is frequently done with an angioplasty balloon In some instances, a defect in the balloon is observed indicating the presence of a stenosis 9

11. Coding This cases should also be coded with 35476/75978 The appearance of the balloon should be used to judge % stenosis compared to what the normal vein should be It should be 50% or greater to warrant the code 10

12. Fibrin Sheath In such a case the fibrin sheath will be removed incidental to the procedure This being the case, it should not be coded The documentation of the case should be based upon the treatment of the venous stenosis and should state that the fibrin sheath was removed incidentally 11

13. Fibrin Sheath Coding If no stenosis is detected (no defect in balloon), removal of a fibrin sheath should be coded as 36595, mechanical removal of pericatheter obstructive material, from a separate location Since the descriptor for this code specifies that it is done from a separate location and in a case such as this it was not, a 52 modifier should be attached The S&I code - 75901 should also be used 12

14. Important Note This document is for informational purposes only and should serve as a guideline for appropriate coding. The ultimate responsibility for correct coding /documentation remains with the provider of service. ASDIN makes no representation, warranty, or guarantee that this compilation of information is error- free, nor that the use of this guide will prevent differences of opinion or disputes with CMS or any other carrier. ASDIN will bear no responsibility or liability for the results or consequences that may grow out of the use of this guidance.