ICD-10-CM Diagnosis Codes
ICD-10-PCS Procedure Codes
CPT® Procedure Codes
HCPCS Supply/DME Codes
ICD-9-CM Diagnosis Codes
Place of Service Codes
UB04 Condition Codes
UB04 Revenue Codes
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
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.
Percutaneous angioplasty may be necessary if, after removal of thrombotic material, blood flow remains inadequate and examination and/or angiography demonstrate residual hemodynamically significant impediment to flow that is caused by other than thrombotic material (residual hemodynamically significant flow impairment may be demonstrated within the fistula at either anastomotic junction or more remotely in the artery or vein providing the fistula’s inflow and outflow).
35475 - Percutaneous balloon angioplasty (arterial).
35476 - Percutaneous balloon angioplasty (venous).
Coverage of CPT 36561 (insertion of tunneled central venous access device, with subcutaneous port) as it relates to this LCD is specific only to vascular access for hemodialysis.
Typically, the clinical examination provides adequate information to determine whether there is hemodynamically significant dialysis shunt dysfunction. The following clinical findings are considered diagnostically specific and appropriate indications to initiate therapies to re-establish physiologically appropriate flow in the dialysis fistula.
Non-Invasive Vascular Studies Used to Monitor the Access Site of End Stage Renal Disease (ESRD) Patients
This clarifies the application of a long-standing Medicare policy regarding services included in the composite rate for ESRD patients. Medicare pays for outpatient maintenance dialysis services furnished by ESRD facilities based on a composite payment rate. This rate is a comprehensive payment and includes all services, equipment, supplies and certain laboratory tests and drugs necessary to furnish a dialysis treatment.
For dialysis to take place, there must be a means of access so that the exchange of waste products may occur. As part of the dialysis treatment, ESRD facilities are responsible for monitoring access and when occlusions occur, either declotting the access or referring the patient for appropriate treatment. Procedures associated with monitoring access involve taking venous pressure, aspirating thrombus, observing elevated recirculation time, reduced urea reduction ratios or collapsed shunt, etc.
A number of ESRD facilities are monitoring access through non-invasive vascular studies such as duplex and Doppler flow scans and billing separately for these procedures. Non-invasive vascular studies are not covered as a separately billable service if used to monitor a patient’s vascular access site. Medicare pays for the technical component of the procedure in the composite payment rate.
An ESRD facility must furnish all necessary services, equipment and supplies associated with a dialysis treatment either directly or under arrangements that make the facility financially responsible for the service. If an ESRD facility or a renal physician decides to monitor the patient’s access site with a non-invasive vascular study and does not have the equipment to perform the procedure, the facility or physician may arrange for the service to be furnished by another source. The alternative source, such as an independent diagnostic testing facility, must look to the ESRD facility for payment. No separate payment for non-invasive vascular studies for monitoring the access site of an ESRD patient, whether coded as the access site or peripheral site, is permitted to any entity.
When there are signs and symptoms of vascular access problems, Doppler flow studies may be used as a means to obtain diagnostic information to permit medical intervention to address the problem. Doppler flow studies may be considered medically necessary in the presence of signs or symptoms of possible failure of the ESRD patient’s vascular access site, and when the results are used to determine the clinical course of the treatment for the patient. The only CPT billing code for non-invasive vascular testing of a hemodialysis access site is 93990. When a dialysis patient exhibits signs and symptoms of compromise to the vascular access site, Doppler flow studies may provide diagnostic information that will determine the appropriate medical intervention. Medicare considers a Doppler flow study medically necessary when the beneficiary’s dialysis access site manifests signs or symptoms associated with vascular compromise and when the results of this test are necessary to determine the clinical course of treatment. Examples supporting the medical necessity for Doppler flow studies include:
Venous Outflow Impediment
Unless the documentation is provided supporting the necessity of more than one study, Medicare will limit payment to either a Doppler flow study or an arteriogram (fistulogram, venogram) but not both. An example of when both studies may be clinically necessary is when a Doppler flow study demonstrates reduced flow (blood flow rate less than 800 cc/min. or a decreased flow of 25 percent or greater from the previous study) and the physician requires an arteriogram to further define the extent of the problem.
Arterial Inflow Impediment
The patient’s medical record(s) must provide documentation supporting the need for more than one imaging study.
This LCD is applicable to claims from ESRD facilities and all other sources such as independent diagnostic testing facilities and hospital outpatient departments.
Notice: Services performed for any given diagnosis must meet the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
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 – Publication 100-02, Chapter 11 ESRD.
- Medicare Benefit Policy Manual – Publication 100-02, Chapter 14, Section 10 and 20.
- Medicare National Coverage Determinations Manual – Publication 100-03, Chapter 1, Sections 20.7, 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) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
Contractor Name(Contractor Number) - Contractor Info
Novitas Solutions, Inc. (07102) - DME Region D
Novitas Solutions, Inc. (07202) - DME Region D
Novitas Solutions, Inc. (07101) - DME Region D
Novitas Solutions, Inc. (07201) - DME Region D
Novitas Solutions, Inc. (07301) - DME Region D
Novitas Solutions, Inc. (07302) - DME Region D
Novitas Solutions, Inc. (04111) - DME Region D
Novitas Solutions, Inc. (04211) - DME Region D
Novitas Solutions, Inc. (04311) - DME Region D
Novitas Solutions, Inc. (04411) - DME Region D
Novitas Solutions, Inc. (04112) - DME Region D
Novitas Solutions, Inc. (04212) - DME Region D
Novitas Solutions, Inc. (04312) - DME Region D
Novitas Solutions, Inc. (04412) - DME Region D
Novitas Solutions, Inc. (04911) - DME Region D
Contractor is not responsible for the continued viability of websites listed.
Key Primary Studies Supporting Covered Indications
Allon M, Daugirdas J, Depner T et al. Effect of Change in Vascular Access on Patient Mortality in Hemodialysis Patients. Am J Kidney Dis 2006; 47 (3): 469-477.
American College of Radiology. Practice Guideline for Endovascular Management of the Thrombosed or Dysfunctional Dialysis Access. http://www.acr.org
American College of Radiology. Practice Guideline for the Performance of Diagnostic Arteriography in Adults. http://www.acr.org
American College of Radiology. Practice Guideline for the Performance of Physiologic Evaluation of Extremity Arteries. http://www.acr.org
American College of Radiology. Practice Guideline for the Performance of Diagnostic Infusion Venography. http://www.acr.org
Aruny J E, Lewis C A, Cardella J F et al. Quality Improvement Guidelines for Percutaneous Management of the Thrombosed to Dysfunctional Dialysis Access. J Vasc Interv Radiol 2003; S247-S253.
Asif A, Lenz O, Cherla G, et al. Percutaneous Management of Perianastomotic Stenosis in Arteriovenous Fistulae: Results of a Prospective Study. Kidney International 2006; 69 1904-1909.
Association for Vascular Access (AVA), American Society of Diagnostic and Interventional Nephrology (ASDIN). Preservation of Peripheral Veins in Patients with Chronic Kidney Disease. Herriman (UT): Association for Vascular Access (AVA); 2008. http://www.guideline.gov
Casey E T, Murad M H, Rizvi A Z, et al. Surveillance of Arteriovenous Hemodialysis Access: A Systematic Review and Meta-Analysis. J Vasc Surg 2008; 48: 48S-54S.
Chang C, Ko P, Hsu L, et al. Highly Increased Cell Proliferation Activity in the Restenotic Hemodialysis Vascular Access After Percutaneous Transluminal Angioplasty: Implication in Prevention of Restenosis. Am J of Kidney Dis 2004; 43 (1): 74-84.
Dossabhoy N R, Ram S J, Nassar R, et al. Stenosis Surveillance of Hemodialysis Grafts by Duplex Ultrasound Reduces Hospitalizations and Cost of Care. Seminars in Dialysis 2005; 18 (6): 550-557.
Duijm L, Liem Y, van der Rijt R et al. Inflow Stenoses in Dysfunctional Hemodialysis Access Fistulae and Grafts Am J Kidney Dis 2006; 48 (1): 98-105.
Lacson E, Lazarus J M, Himmelfard J et al. Balancing Fistula First With Catheters Last. Am J Kidney Dis 2007; 50 (3): 379-395.
Levin A and Rocco M, and The Vascular Access 2006 Membership. NKF KDOQI Clinical Practice Guidelines for Vascular Access. Am J Kidney Dis 2006; 48 (1): S176-S247.
Malik J. Letter to the Editor and reply by the Authors’ Re: Robbin M L et al. Ultrasonography and graft patency. Kidney International 2006; 70 1375-1376.
Maya I, and Allon M. Vascular Access: Core Curriculum 2008. Am J Kidney Dis 2008; 51 (4):702-708.
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.
Polkinghorne K. Vascular Access Practice in Hemodialysis: Instrumental in Determining Patient Mortality. Am J Kidney Dis 2009; 53 (3): 359-362.
Ram S J, Nassar R, Sharaf R, et al. Thresholds for Significant Decrease in Hemodialysis Access Blood Flow. Seminars in Dialysis 2005; 18 (6) 558-564.
Robbin ML, Oiser RF, Lee JY, et al. Randomized Comparison of Ultrasound Surveillance and Clinical Monitoring in Arteriovenous Graft Outcomes. Kidney International 2006; 69 730-735
Roy-Chaudhury P, Arend L, Zhang J et al. Neointimal Hyperplasia in Early Arteriovenous Fistula Failure. Am J Kidney Dis 2006; 50 (5) 782-790.
Sacks D, McClenny T E, Cardella J F, et al. Society of Interventional Radiology Clinical Practice Guidelines. J Vasc Radiol 2003; 14:S199-S202.
Sidawy A N, Spergel L M, Besarab A et al. The Society for Vascular Surgery: Clinical Practice Guidelines for the Surgical Placement and Maintenance of Arteriovenous Hemodialysis Access. J Vasc Surg 2008; 48 2S-25S.
Singh N, Starnes B, and Andersen C. Successful Angioaccess. Surg Clin N Am 2007; 87: 1213-1228.
Tonelli M, James M, Wiebe N et al. Ultrasound Monitoring to Detect Access Stenosis in Hemodialysis Patients: A Systematic Review. Am J Kidney Dis 2008; 51 (4): 630-640.
Tuka V and Malik J. Letter to Editor and Reply by the Authors. Re: Tonelli, et al (above): Vascular Access Surveillance: No Benefit? Am J Kidney Dis 2008; 52 (3): 628-629.
Wang H J and Yang YF, Percutaneous Treatment of Dysfunctional Brescia – Cimino Fistulae Through a Radial Arterial Approach. Am J Kidney Dis 2006; 48 (4): 652-658.
Other Contractor Policies
Contractor Medical Directors
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
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.0320 - Radiology - Diagnostic - General Classification
0329 - Radiology - Diagnostic - Other Radiology - Diagnostic
0360 - Operating Room Services - General Classification
0361 - Operating Room Services - Minor Surgery
0369 - Operating Room Services - Other OR Services
0450 - Emergency Room - General Classification
0490 - Ambulatory Surgical Care - General Classification
0520 - Free-Standing Clinic - General Classification
0521 - Free-Standing Clinic - Clinic Visit by Member to RHC/FQHC
0920 - Other Diagnostic Services - General Classification
0921 - Other Diagnostic Services - Peripheral Vascular Lab
0929 - Other Diagnostic Services - Other Diagnostic Service
0960 - Professional Fees - General Classification
0981 - Professional Fees - Emergency Room Services
0982 - Professional Fees - Outpatient Services
0983 - Professional Fees - Clinic
Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes.
Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books.
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 36831 36832 36833 36870 37607 37799 75710 75791 75820 75827 75901 75902 75962 75978 93990
All those not listed under the