2. Treatment of Hand Ischemia Dialysis Associated Steal Syndrome (DASS) ASDIN Coding University 1

3. DASS The evaluation of dialysis access associated steal syndrome (DASS) in the interventional facility generally begins with evaluation of the hand/vascular access complex Ultrasound evaluation of access with flow measurement – The type of procedure performed to treat the problem is dependent upon the level of flow present within the access Arteriogram of artery proximal and distal to anastomosis – Hand ischemia may be secondary to arterial lesions in the feeding artery or the artery perfusing the hand 2

4. Ultrasound Evaluation of Vascular Access 93990 is the code for ultrasound evaluation of the vascular access The descriptor for this code is – duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) 3

5. Required Elements of Study This study must include all components of the access – Arterial inflow – Body of access – Venous outflow Since the descriptor specifically states “duplex ultrasound”, the study must include: – 2D (B mode) ultrasound to visualize anatomy – Doppler ultrasound to assess flow (See unit of US of Vascular Access for more details) 4

6. Arteriogram The code for an arteriogram is 75710 – Descriptor – angiogram, extremity, unilateral, radiological supervision and interpretation – If 75710 is applied in conjunction with a therapeutic RS&I code, it should have a 59 modifier attached An examination of the artery adjacent to the arterial anastomosis is included in the 36147 code This should be interpreted as being within approximately 2 cm of the anastomosis Use of the 75710 code would be warranted only if a larger segment of the artery is examined – In this situation examination of the feeding artery up to the aortic arch and the artery perfusing the hand is generally medically indicated 5

7. Using More Than 1 Modality to Image Under ordinary circumstances imaging of the same vascular structure by more than one modality on the same day should not be coded However, both an arteriogram and an ultrasound can be coded if required to further define the nature and extent of the problem The evaluation of dialysis associated hand ischemia represents such a situation It is very important in this situation that the patient’s medical record provide adequate documentation supporting the need for more than one imaging study 6

8. Interventional Treatment Some cases of DASS are amendable to treatment by interventional means – Upper arm access – DASS associated with a high flow brachial artery based access Balloon assisted banding – Forearm access - DASS associated with a radial-cephalic AVF Distal radial artery embolization 7

9. Treatment of Upper Arm Access Associated DASS Balloon assisted banding has been used to treat this problem This procedure starts with basic cannulation – 36147 – Done prior to the arteriogram described above For the banding procedure 37607 is recommended The descriptor for 37607 is – ligation or banding of angioaccess arteriovenous fistula Follow-up angiograms are considered to be part of the basic procedure and do not warrant a separate code 8

10. Treatment of DASS Associated with Forearm Access Placing an embolization coil in the distal radial artery has been used to treat this problem This procedure starts with basic cannulation – 36147 – Done prior to the arteriogram described above The additional codes that should be used would depend upon the requirements of the procedure 9

11. Selective Catheterization Selective cannulation of a first order artery (the radial artery) may be required. In this instance the code 36215 would be warranted The descriptor for 36215 is – selective catheter placement, arterial system, each first order thoracic or brachiocephalic branch, within a vascular family The use of this code would require dropping the cannulation portion of 36147 while retaining the angiogram component, 75791 (See unit of Cannulation /Catheterization for more details) 10

12. Embolization Coil Placem ent The occlusion of the distal radial artery is generally accomplished using an embolization coil The code for the insertion of an embolization coil is 37204 The descriptor for 37204 is - transcatheter occlusion or embolization, percutaneous, any method, non-central nervous system, non-head or neck An RS&I code goes with this code - 75894 The descriptor for this code is - transcatheter therapy, embolization, any method, radiological supervision and interpretatio n 11

13. Post Coil Placement Angiogram Unlike other post-procedure angiograms, it is possible to code for a follow-up angiogram following the placement of an embolization coil if medically indicated The code for this procedure 75898 The descriptor for this code is angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion As the descriptor indicates for this angiogram, performing it through the catheter that is in place (for insertion of the coil) is required 12

14. Use of Diagnostic and Therapeutic RS&I Codes Togethe r When a diagnostic RS&I code is used in association with a therapeutic RS&I code, a 59 modifier should be attached to the former In the instance described here – there are 2 diagnostic RS&I codes and 1 therapeutic RS&I code The embolization coil placement is a therapeutic RS&I The post-coil angiogram via catheter RS&I is diagnostic The initial arteriogram RS&I described earlier is also diagnostic The diagnostic codes should have a 59 modifier attached 13

15. 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. 14