CPT® Procedure Codes
HCPCS Supply/DME Codes
ICD-9-CM Diagnosis Codes
DRGs & APCs
ICD-10-CM Diagnosis Codes
ICD-10-PCS Procedure Codes
Place of Service Codes
UB04 Condition Codes
UB04 Revenue Codes
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
In keeping with the CMS' national initiative, Fistula First project, Medicare would expect that wherever an AV fistula (native arteriovenous fistula) is feasible, the AV fistula will be used. The objective is to restore appropriate flow, preserve the fistula's functional integrity and avoid the need to create a new fistula. In order to increase the appropriate use of AV fistulae for hemodialysis access, Preoperative Venous Mapping (93970 and 93971) is considered medically indicated in patients with ESRD.
Percutaneous interventions to enhance or re-establish patency of a hemodialysis fistula have proven useful in extending the life of the fistula and reducing the need for open repair. Percutaneous fistula declotting for the re-establishment of appropriate and adequate flow may encompass the following procedures. They need not all be performed on every dysfunctional fistula.
36147© Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access of shunt, injection[s] of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava)
36148© Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); additional access for therapeutic intervention (list separately in addition to code for primary procedure)
36870© - Thrombectomy including mechanical extraction and intra-graft thrombolysis.
These procedures may be necessary if, after removal of thrombotic material, blood flow remains inadequate and examination and/or vascular imaging demonstrate residual hemodynamically significant impairment to flow.
The following codes for diagnostic angiography would be expected to image flow prior to intervention when medically indicated:
75710© - Angiography, extremity, unilateral, radiological supervision and interpretation.
75791© Angiography, arteriovenous shunt (eg, dialysis patient fistula/graft), complete evaluation of dialysis access, including fluoroscopy, image documentation and report (includes injections of contrast and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava), radiological supervision and interpretation
Typically, the physician's clinical examination may provide adequate findings to suggest impairment of flow. The clinical findings listed below may be appropriate indications for either direct therapeutic intervention or confirmatory imaging studies such as ultrasonography or angiography. When physical findings are clearly confirmatory of obstruction to flow, it is preferable to proceed to fistulography directly, as there is little derived value from performing ultrasonography. Further testing is also appropriate when the indirect measurements of Urea Reduction Ratio of the Dialysis Flow Rate X Time/Volume (KT/V) indicate the quality of dialysis has fallen.
This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Vascular Access for Hemodialysis. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for Vascular Access for Hemodialysis and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies regarding Vascular Access for Hemodialysis are found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:
- Medicare Benefit Policy Manual - Pub. 100-02, Chapter 11 ESRD.
- Medicare National Coverage Determinations Manual - Pub. 100-03, Chapter 1, Sections 110.15, 230.
- Correct Coding Initiative - Medicare Contractor Beneficiary and Provider Communications Manual - Pub. 100-09, Chapter 5.
- Social Security Act (Title XVIII) Standard References, Sections:
- 1862(a)(1)(A) Medically Reasonable & Necessary.
- 1862(a)(1)(D) Investigational or Experimental.
- 1862(a)(7) Screening (Routine Physical Checkups).
- 1833(e) Incomplete Claim.
Jurisdiction "H" Notice:
Jurisdiction "H" comprises the states of Arkansas, Louisiana, Mississippi, Colorado, New Mexico, Oklahoma, and Texas. Novitas is responsible for claims payment and Local Coverage Determination (LCD) development for this jurisdiction. This LCD was created as a part of the legacy transition (8/13/2012 - 11/19/2012); and, is a consolidation of the previous legacy contractors' policies. Coverage of each LCD begins when the state/contract number combination officially is integrated into the Jurisdiction. On the CMS MCD, this date is known as either the Original Effective Date or the Revision Effective Date. The following table details the official effective dates for each state/contract number combination.
ST Legacy A
J "H" MAC A
J "H" MAC B
AR PBSI: 00520 (J7) Novitas: 07102 08/13/12 LA PBSI: 00528 (J7) Novitas: 07202 08/13/12 AR PBSI: 00020 (J7) Novitas: 07101 08/20/12 LA PBSI: 00233 (J7) Novitas: 07201 08/20/12 MS PBSI: 00233 (J7) Novitas: 07301 08/20/12 MS Cahaba: 00512 (J7) Novitas: 07302 10/22/12 J 4
Trailblazer: 04901 Novitas: 04911 10/29/12 CO Trailblazer: 04101 Novitas: 04111 10/29/12 NM Trailblazer: 04201 Novitas: 04211 10/29/12 OK Trailblazer: 04301 Novitas: 04311 10/29/12 TX Trailblazer: 04401 Novitas: 04411 10/29/12 CO Trailblazer: 04102 Novitas: 04112 11/19/12 NM Trailblazer: 04202 Novitas: 04212 11/19/12 OK Trailblazer: 04302 Novitas: 04312 11/19/12 TX Trailblazer: 04402 Novitas: 04412 11/19/12
Contractor Name(Contractor Number) - Contractor Info
11/19/2012 (Revision History Number 5) Per CMS Change Request (CR) 7812, this LCD has been updated with the original effective date of 11/19/2012 to add the Novitas Jurisdiction H Part B MAC Contract Numbers 04112, 04212, 04312, and 04412 for Colorado Part B, New Mexico Part B, Oklahoma Part B, Texas Part B, Indian Health Service (IHS)/Tribal/Urban Indian Providers Part B, and Veterans Affairs (VA) Part B. No other changes were made to this LCD.
10/29/2012 (Revision History Number 4) Per CMS Change Request (CR) 7812, this LCD has been updated with the original effective date of 10/29/2012 to add the Novitas Jurisdiction H Part A MAC Contract Numbers 04911, 04111, 04211, 04311, and 04411 for Colorado Part A, New Mexico Part A, Oklahoma Part A, Texas Part A, Indian Health Service (IHS)/Tribal/Urban Indian Providers Part A, and Veterans Affairs (VA) Part A. No other changes were made to this LCD.
10/22/2012 (Revision History Number 3) LCD original effective date of 10/22/2012 for Mississippi Part B.
08/20/2012 (Revision History Number 2) LCD original effective date of 08/20/2012 for Arkansas Part A, Louisiana Part A, and Mississippi A.
08/13/2012 (Revision History Number 1) LCD original effective date of 08/13/2012 for Arkansas Part B and Louisiana Part B. LCD posted for notice on 06/28/2012.
Key Primary Studies Supporting Covered Indications
National Kidney Foundation - Dialysis Outcomes Quality Initiative Vascular Access GuidelinesTM 19997, Guideline Nos. 1, 2, 3, 5, 6, 8, 10, 11, 17, 18, 20, 21.
Other Contractor Local Coverage Determinations
"Vascular Access for Hemodialysis," TrailBlazer Health Enterprises, LLC LCD, (00400) L13357, (00900) L13364.
"Percutaneous Thrombectomy of Arteriovenous Fistula/Graft," Arkansas BlueCross BlueShield (Pinnacle) LCD, (OK, NM) L14794.
Novitas Solutions, Inc. - JH Local Coverage Determination (LCD) Consolidation
Narrative Justification - Most Clinically Appropriate LCD
L26737, Vascular Access for Hemodialysis, TrailBlazer, CO,M,K, TX, Indian Health Service, ESRD, SNF, RHC, WPS legacy - A/B
L14794, Percutaneous Thrombectomy of Arteriovenous Fistula/graft, Pinnacle, Louisiana - B
L30990, Percutaneous Thrombectomy of Arteriovenous Fistula/Graft, Pinnacle, Louisiana, Mississippi - A
L19148, Percutaneous Thrombectomy of Arteriovenous Fistula/Graft, Pinnacle, Arkansas - A
L14794, Percutaneous Thrombectomy of Arteriovenous Fistula/Graft, Pinnacle, Arkansas - B
This service is generally an area of overutilization in most territories.
TrailBlazer and Pinnacle have policies on this issue. The TrailBlazer policy covers more codes. It suggests the appropriate use of Ultrasound, as well.
The Pinnacle policy has similar CPT and ICD codes to the TrailBlazer policy.
Both policies have diagnosis to procedure code editing.
The Pinnacle policy includes utilization parameters with regard to PSPMT or intermittent boluses of anticoagulant and how those should be billed (integral to 36870). It also instructs that radiologic codes should be used only once in general, during a course of treatment. These statements make this policy attractive.
However, the ultrasound piece and the combining of Parts A and B in one document make the TrailBlazer document the better choice for retention on this topic. L26737 is the most clinically appropriate LCD.
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.11 - Hospital Inpatient (Including Medicare Part A)
13 - Hospital Outpatient
18 - Hospital - Swing Beds
21 - Skilled Nursing - Inpatient (Including Medicare Part A)
22 - Skilled Nursing - Inpatient (Medicare Part B only)
23 - Skilled Nursing - Outpatient
28 - Skilled Nursing - Swing Beds
71 - Clinic - Rural Health
72 - Clinic - Hospital Based or Independent Renal Dialysis Center
73 - Clinic - Freestanding
77 - Clinic - Federally Qualified Health Center (FQHC)
83 - Ambulatory Surgery Center
85 - Critical Access Hospital
Bill Type Note (above) : Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.0333 - Radiology - Therapeutic and/or Chemotherapy Administration - Radiation Therapy
Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Publication 100-04, Claims Processing Manual, for further guidance.
0340 - Nuclear Medicine - General Classification
0341 - Nuclear Medicine - Diagnostic
0342 - Nuclear Medicine - Therapeutic
0343 - Nuclear Medicine - Diagnostic Radiopharmaceuticals
0344 - Nuclear Medicine - Therapeutic Radiopharmaceuticals
0349 - Nuclear Medicine - Other Nuclear Medicine
0350 - CT Scan - General Classification
0351 - CT Scan - CT - Head Scan
0352 - CT Scan - CT - Body Scan
0359 - CT Scan - CT Other
0360 - Operating Room Services - General Classification
0361 - Operating Room Services - Minor Surgery
0362 - Operating Room Services - Organ Transplant - Other than Kidney
0367 - Operating Room Services - Kidney Transplant
0369 - Operating Room Services - Other OR Services
0400 - Other Imaging Services - General Classification
0401 - Other Imaging Services - Diagnostic Mammography
0402 - Other Imaging Services - Ultrasound
0403 - Other Imaging Services - Screening Mammography
0404 - Other Imaging Services - Positron Emission Tomography
0409 - Other Imaging Services - Other Imaging Services
0450 - Emergency Room - General Classification
0451 - Emergency Room - EMTALA Emergency Medical Screening
0452 - Emergency Room - ER Beyond EMTALA
0456 - Emergency Room - Urgent Care
0459 - Emergency Room - Other Emergency Room
0490 - Ambulatory Surgical Care - General Classification
0499 - Ambulatory Surgical Care - Other Ambulatory Surgical
0610 - Magnetic Resonance Technology (MRT) - General Classification
0611 - Magnetic Resonance Technology (MRT) - MRI - Brain/Brainstem
0612 - Magnetic Resonance Technology (MRT) - MRI - Spinal Cord/Spine
0614 - Magnetic Resonance Technology (MRT) - MRI - Other
0615 - Magnetic Resonance Technology (MRT) - MRA - Head and Neck
0616 - Magnetic Resonance Technology (MRT) - MRA - Lower Extremities
0618 - Magnetic Resonance Technology (MRT) - MRA - Other
0619 - Magnetic Resonance Technology (MRT) - Other MRT
0761 - Specialty Services - Treatment Room
Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
Note: Medicare would expect to see the following codes (excluding 36819 and 36821) accompanied by the CPT codes 36819 and 36821 for native AV fistulae, unless placement is medically precluded and appropriate documentation is maintained in the medical record (see LCD Abstract).
34101 34111 35475 35476 36005 36010 36147 36148 36215 36216 36217 36556 36558 36561 36563 36565 36566 36569 36571 36575 36576 36578 36580 36581 36582 36583 36584 36585 36593 36597 36598 36800 36810 36815 36819 36821 36825 36832 36833 36870 37607 37799 75710 75791 75820 75827 75901 75902 75962 75978 93990
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
When procedure codes 35475, 35476, 36147, 36148, 36556, 36558, 36561, 36563, 36565, 36566, 36569, 36571, 36575, 36576, 36578, 36580, 36581, 36582, 36583, 36584, 36585, 36593, 36597, 36598, 36870, 75710, 75791, 75820, 75962, 75978 and 93990 are used to report the services described in this LCD (appropriate evaluation of the patency of an established hemodialysis fistula and the percutaneous interventions needed to enhance or re-establish patency of that hemodialysis fistula), the following diagnosis codes will be considered by Medicare to support medical necessity:
440.31 440.32 442.0 442.3 444.21 444.22 447.0 447.1 451.82 453.40 453.41 453.42 453.50 453.51 453.52 453.6 453.71 453.72 453.73 453.74 453.75 453.76 453.77 453.79 453.81 453.82 453.83 453.84 453.85 453.86 453.87 453.89 459.2 996.1 996.62 996.73 996.74
Medicare Policies and Guidelines - NCD, LCD, Articles, LMRP
Summary: Medicare Policies and Guidelines - NCD, LCD, Articles, LMRP
Keywords: Medicare Policies and Guidelines, NCD, LCD, LMRP, national coverage determinations, local coverage determinations, local medical review policies
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