Archive
API

LCD Reference Article Billing and Coding Article

Billing and Coding: Dialysis Access Maintenance

A56460

Expand All | Collapse All
Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56460
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Dialysis Access Maintenance
Article Type
Billing and Coding
Original Effective Date
01/01/2018
Revision Effective Date
02/01/2024
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

N/A

Article Guidance

Article Text

This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L34062-Dialysis Access Maintenance.

 

General Guidelines for Claims submitted to Part A or Part B MAC:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

 

Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.

 

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.

 

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. ‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.

Documentation Requirements

The patient’s medical record should include but is not limited to:

  • The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  • Relevant medical history
  • Results of pertinent tests/procedures
  • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

 

 

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
018x Hospital - Swing Beds
021x Skilled Nursing - Inpatient (Including Medicare Part A)
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
028x Skilled Nursing - Swing Beds
072x Clinic - Hospital Based or Independent Renal Dialysis Center
085x Critical Access Hospital
N/A

Revenue Codes

Code Description
0320 Radiology - Diagnostic - General Classification
0329 Radiology - Diagnostic - Other Radiology - Diagnostic
0350 CT Scan - General Classification
0351 CT Scan - Head Scan
0352 CT Scan - Body Scan
0359 CT Scan - CT - Other
0360 Operating Room Services - General Classification
0361 Operating Room Services - Minor Surgery
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
0490 Ambulatory Surgical Care - General Classification
0510 Clinic - General Classification
0511 Clinic - Chronic Pain Center
0512 Clinic - Dental Clinic
0513 Clinic - Psychiatric Clinic
0514 Clinic - OB-GYN Clinic
0515 Clinic - Pediatric Clinic
0516 Clinic - Urgent Care Clinic
0517 Clinic - Family Practice Clinic
0519 Clinic - Other Clinic
0520 Freestanding Clinic - General Classification
0521 Freestanding Clinic - Clinic Visit by Member to RHC/FQHC
0761 Specialty Services - Treatment Room
0920 Other Diagnostic Services - General Classification
0921 Other Diagnostic Services - Peripheral Vascular Lab
0929 Other Diagnostic Services - Other Diagnostic Service
0940 Other Therapeutic Services - General Classification
0960 Professional Fees - General Classification
0981 Professional Fees - Emergency Room Services
0982 Professional Fees - Outpatient Services
0983 Professional Fees - Clinic
N/A

CPT/HCPCS Codes

Expand All | Collapse All

Group 1

(38 Codes)
Group 1 Paragraph

N/A

 Group 1 Codes
Code Description
36005 INJECTION PROCEDURE FOR EXTREMITY VENOGRAPHY (INCLUDING INTRODUCTION OF NEEDLE OR INTRACATHETER)
36010 INTRODUCTION OF CATHETER, SUPERIOR OR INFERIOR VENA CAVA
36140 INTRODUCTION OF NEEDLE OR INTRACATHETER, UPPER OR LOWER EXTREMITY ARTERY
36215 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY
36216 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY
36217 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY
36218 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; ADDITIONAL SECOND ORDER, THIRD ORDER, AND BEYOND, THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY (LIST IN ADDITION TO CODE FOR INITIAL SECOND OR THIRD ORDER VESSEL AS APPROPRIATE)
36245 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY
36246 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY
36247 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY
36593 DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCESS DEVICE OR CATHETER
36831 THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)
36832 REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)
36833 REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)
36901 INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;
36902 INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY
36903 INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS SEGMENT
36904 PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S);
36905 PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY
36906 PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS CIRCUIT
36907 TRANSLUMINAL BALLOON ANGIOPLASTY, CENTRAL DIALYSIS SEGMENT, PERFORMED THROUGH DIALYSIS CIRCUIT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
37186 SECONDARY PERCUTANEOUS TRANSLUMINAL THROMBECTOMY (EG, NONPRIMARY MECHANICAL, SNARE BASKET, SUCTION TECHNIQUE), NONCORONARY, NON-INTRACRANIAL, ARTERIAL OR ARTERIAL BYPASS GRAFT, INCLUDING FLUOROSCOPIC GUIDANCE AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS, PROVIDED IN CONJUNCTION WITH ANOTHER PERCUTANEOUS INTERVENTION OTHER THAN PRIMARY MECHANICAL THROMBECTOMY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
37211 TRANSCATHETER THERAPY, ARTERIAL INFUSION FOR THROMBOLYSIS OTHER THAN CORONARY OR INTRACRANIAL, ANY METHOD, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION, INITIAL TREATMENT DAY
37212 TRANSCATHETER THERAPY, VENOUS INFUSION FOR THROMBOLYSIS, ANY METHOD, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION, INITIAL TREATMENT DAY
37213 TRANSCATHETER THERAPY, ARTERIAL OR VENOUS INFUSION FOR THROMBOLYSIS OTHER THAN CORONARY, ANY METHOD, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION, CONTINUED TREATMENT ON SUBSEQUENT DAY DURING COURSE OF THROMBOLYTIC THERAPY, INCLUDING FOLLOW-UP CATHETER CONTRAST INJECTION, POSITION CHANGE, OR EXCHANGE, WHEN PERFORMED;
37214 TRANSCATHETER THERAPY, ARTERIAL OR VENOUS INFUSION FOR THROMBOLYSIS OTHER THAN CORONARY, ANY METHOD, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION, CONTINUED TREATMENT ON SUBSEQUENT DAY DURING COURSE OF THROMBOLYTIC THERAPY, INCLUDING FOLLOW-UP CATHETER CONTRAST INJECTION, POSITION CHANGE, OR EXCHANGE, WHEN PERFORMED; CESSATION OF THROMBOLYSIS INCLUDING REMOVAL OF CATHETER AND VESSEL CLOSURE BY ANY METHOD
37236 TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY
37237 TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; EACH ADDITIONAL ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
37246 TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY
37247 TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; EACH ADDITIONAL ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
37248 TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME VEIN; INITIAL VEIN
37249 TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME VEIN; EACH ADDITIONAL VEIN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
75710 ANGIOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION
75820 VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION
75822 VENOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION
75825 VENOGRAPHY, CAVAL, INFERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION
75827 VENOGRAPHY, CAVAL, SUPERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION
93990 DUPLEX SCAN OF HEMODIALYSIS ACCESS (INCLUDING ARTERIAL INFLOW, BODY OF ACCESS AND VENOUS OUTFLOW)
N/A

CPT/HCPCS Modifiers

Expand All | Collapse All

Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Expand All | Collapse All

Group 1

(122 Codes)
Group 1 Paragraph

It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

36005, 36010, 36140, 36215, 36216, 36217, 36218, 36245, 36246, 36247, 36593, 36831, 36832, 36833, 36901, 36902, 36903, 36904, 36905, 36906, 36907, 37186, 37211, 37212, 37213, 37214, 37236, 37237, 37246, 37247, 37248, 37249, 75710, 75820, 75822, 75825, 75827

 Group 1 Codes
Code Description
I70.401 - I70.403 Unspecified atherosclerosis of autologous vein bypass graft(s) of the extremities, right leg - Unspecified atherosclerosis of autologous vein bypass graft(s) of the extremities, bilateral legs
I70.408 Unspecified atherosclerosis of autologous vein bypass graft(s) of the extremities, other extremity
I70.411 - I70.413 Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, right leg - Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, bilateral legs
I70.418 Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, other extremity
I70.421 - I70.423 Atherosclerosis of autologous vein bypass graft(s) of the extremities with rest pain, right leg - Atherosclerosis of autologous vein bypass graft(s) of the extremities with rest pain, bilateral legs
I70.428 Atherosclerosis of autologous vein bypass graft(s) of the extremities with rest pain, other extremity
I70.431 - I70.435 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of thigh - Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of foot
I70.441 - I70.445 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of thigh - Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of foot
I70.45 Atherosclerosis of autologous vein bypass graft(s) of other extremity with ulceration
I70.461 - I70.463 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, right leg - Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, bilateral legs
I70.468 Atherosclerosis of autologous vein bypass graft(s) of the extremities with gangrene, other extremity
I70.491 - I70.493 Other atherosclerosis of autologous vein bypass graft(s) of the extremities, right leg - Other atherosclerosis of autologous vein bypass graft(s) of the extremities, bilateral legs
I70.498 Other atherosclerosis of autologous vein bypass graft(s) of the extremities, other extremity
I70.501 - I70.503 Unspecified atherosclerosis of nonautologous biological bypass graft(s) of the extremities, right leg - Unspecified atherosclerosis of nonautologous biological bypass graft(s) of the extremities, bilateral legs
I70.508 Unspecified atherosclerosis of nonautologous biological bypass graft(s) of the extremities, other extremity
I70.511 - I70.513 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent claudication, right leg - Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent claudication, bilateral legs
I70.518 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent claudication, other extremity
I70.521 - I70.523 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with rest pain, right leg - Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with rest pain, bilateral legs
I70.528 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with rest pain, other extremity
I70.531 - I70.535 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of thigh - Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of foot
I70.541 - I70.545 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of thigh - Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other part of foot
I70.55 Atherosclerosis of nonautologous biological bypass graft(s) of other extremity with ulceration
I70.561 - I70.563 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, right leg - Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, bilateral legs
I70.568 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, other extremity
I70.591 - I70.593 Other atherosclerosis of nonautologous biological bypass graft(s) of the extremities, right leg - Other atherosclerosis of nonautologous biological bypass graft(s) of the extremities, bilateral legs
I70.598 Other atherosclerosis of nonautologous biological bypass graft(s) of the extremities, other extremity
I72.1 Aneurysm of artery of upper extremity
I72.4 Aneurysm of artery of lower extremity
I74.2 Embolism and thrombosis of arteries of the upper extremities
I74.3 Embolism and thrombosis of arteries of the lower extremities
I77.0 Arteriovenous fistula, acquired
I77.1 Stricture of artery
I80.8 Phlebitis and thrombophlebitis of other sites
I82.611 - I82.613 Acute embolism and thrombosis of superficial veins of right upper extremity - Acute embolism and thrombosis of superficial veins of upper extremity, bilateral
I87.1 Compression of vein
M79.89 Other specified soft tissue disorders
N18.6 End stage renal disease
T82.310A Breakdown (mechanical) of aortic (bifurcation) graft (replacement), initial encounter
T82.311A Breakdown (mechanical) of carotid arterial graft (bypass), initial encounter
T82.312A Breakdown (mechanical) of femoral arterial graft (bypass), initial encounter
T82.318A Breakdown (mechanical) of other vascular grafts, initial encounter
T82.320A Displacement of aortic (bifurcation) graft (replacement), initial encounter
T82.321A Displacement of carotid arterial graft (bypass), initial encounter
T82.322A Displacement of femoral arterial graft (bypass), initial encounter
T82.328A Displacement of other vascular grafts, initial encounter
T82.330A Leakage of aortic (bifurcation) graft (replacement), initial encounter
T82.331A Leakage of carotid arterial graft (bypass), initial encounter
T82.332A Leakage of femoral arterial graft (bypass), initial encounter
T82.338A Leakage of other vascular grafts, initial encounter
T82.390A Other mechanical complication of aortic (bifurcation) graft (replacement), initial encounter
T82.391A Other mechanical complication of carotid arterial graft (bypass), initial encounter
T82.392A Other mechanical complication of femoral arterial graft (bypass), initial encounter
T82.398A Other mechanical complication of other vascular grafts, initial encounter
T82.41XA Breakdown (mechanical) of vascular dialysis catheter, initial encounter
T82.42XA Displacement of vascular dialysis catheter, initial encounter
T82.43XA Leakage of vascular dialysis catheter, initial encounter
T82.49XA Other complication of vascular dialysis catheter, initial encounter
T82.510A Breakdown (mechanical) of surgically created arteriovenous fistula, initial encounter
T82.511A Breakdown (mechanical) of surgically created arteriovenous shunt, initial encounter
T82.513A Breakdown (mechanical) of balloon (counterpulsation) device, initial encounter
T82.514A Breakdown (mechanical) of infusion catheter, initial encounter
T82.515A Breakdown (mechanical) of umbrella device, initial encounter
T82.518A Breakdown (mechanical) of other cardiac and vascular devices and implants, initial encounter
T82.520A Displacement of surgically created arteriovenous fistula, initial encounter
T82.521A Displacement of surgically created arteriovenous shunt, initial encounter
T82.523A Displacement of balloon (counterpulsation) device, initial encounter
T82.524A Displacement of infusion catheter, initial encounter
T82.525A Displacement of umbrella device, initial encounter
T82.528A Displacement of other cardiac and vascular devices and implants, initial encounter
T82.529A Displacement of unspecified cardiac and vascular devices and implants, initial encounter
T82.530A Leakage of surgically created arteriovenous fistula, initial encounter
T82.531A Leakage of surgically created arteriovenous shunt, initial encounter
T82.533A Leakage of balloon (counterpulsation) device, initial encounter
T82.534A Leakage of infusion catheter, initial encounter
T82.535A Leakage of umbrella device, initial encounter
T82.538A Leakage of other cardiac and vascular devices and implants, initial encounter
T82.590A Other mechanical complication of surgically created arteriovenous fistula, initial encounter
T82.591A Other mechanical complication of surgically created arteriovenous shunt, initial encounter
T82.593A Other mechanical complication of balloon (counterpulsation) device, initial encounter
T82.594A Other mechanical complication of infusion catheter, initial encounter
T82.595A Other mechanical complication of umbrella device, initial encounter
T82.598A Other mechanical complication of other cardiac and vascular devices and implants, initial encounter
T82.7XXA Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter
Z99.2 Dependence on renal dialysis

Group 2

(7 Codes)
Group 2 Paragraph

It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

36005, 36010, 36140, 36215, 36216, 36217, 36218, 36245, 36246, 36247, 36593, 36831, 36832, 36833, 36901, 36902, 36903, 36904, 36905, 36906, 36907, 37186, 37211, 37212, 37213, 37214, 37236, 37237, 37246, 37247, 37248, 37249, 75710, 75820, 75822, 75825, 75827


ICD-10-CM codes are the codes that describes ESRD with malfunctioning dialysis access (grafts or fistulae).

 Group 2 Codes
Code Description
T82.818A Embolism due to vascular prosthetic devices, implants and grafts, initial encounter
T82.828A Fibrosis due to vascular prosthetic devices, implants and grafts, initial encounter
T82.838A Hemorrhage due to vascular prosthetic devices, implants and grafts, initial encounter
T82.848A Pain due to vascular prosthetic devices, implants and grafts, initial encounter
T82.858A Stenosis of other vascular prosthetic devices, implants and grafts, initial encounter
T82.868A Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter
T82.898A Other specified complication of vascular prosthetic devices, implants and grafts, initial encounter

Group 3

(17 Codes)
Group 3 Paragraph

93990

 Group 3 Codes
Code Description
I77.0 Arteriovenous fistula, acquired
I97.89 Other postprocedural complications and disorders of the circulatory system, not elsewhere classified
T82.818A Embolism due to vascular prosthetic devices, implants and grafts, initial encounter
T82.818S Embolism due to vascular prosthetic devices, implants and grafts, sequela
T82.828A Fibrosis due to vascular prosthetic devices, implants and grafts, initial encounter
T82.828S Fibrosis due to vascular prosthetic devices, implants and grafts, sequela
T82.838A Hemorrhage due to vascular prosthetic devices, implants and grafts, initial encounter
T82.838S Hemorrhage due to vascular prosthetic devices, implants and grafts, sequela
T82.848A Pain due to vascular prosthetic devices, implants and grafts, initial encounter
T82.848S Pain due to vascular prosthetic devices, implants and grafts, sequela
T82.858A Stenosis of other vascular prosthetic devices, implants and grafts, initial encounter
T82.858S Stenosis of other vascular prosthetic devices, implants and grafts, sequela
T82.868A Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter
T82.868S Thrombosis due to vascular prosthetic devices, implants and grafts, sequela
T82.898A Other specified complication of vascular prosthetic devices, implants and grafts, initial encounter
T82.898S Other specified complication of vascular prosthetic devices, implants and grafts, sequela
Z99.2 Dependence on renal dialysis
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Expand All | Collapse All

Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Expand All | Collapse All

Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
018x Hospital - Swing Beds
021x Skilled Nursing - Inpatient (Including Medicare Part A)
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
028x Skilled Nursing - Swing Beds
072x Clinic - Hospital Based or Independent Renal Dialysis Center
085x Critical Access Hospital
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.
Code Description
0320 Radiology - Diagnostic - General Classification
0329 Radiology - Diagnostic - Other Radiology - Diagnostic
0350 CT Scan - General Classification
0351 CT Scan - Head Scan
0352 CT Scan - Body Scan
0359 CT Scan - CT - Other
0360 Operating Room Services - General Classification
0361 Operating Room Services - Minor Surgery
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
0490 Ambulatory Surgical Care - General Classification
0510 Clinic - General Classification
0511 Clinic - Chronic Pain Center
0512 Clinic - Dental Clinic
0513 Clinic - Psychiatric Clinic
0514 Clinic - OB-GYN Clinic
0515 Clinic - Pediatric Clinic
0516 Clinic - Urgent Care Clinic
0517 Clinic - Family Practice Clinic
0519 Clinic - Other Clinic
0520 Freestanding Clinic - General Classification
0521 Freestanding Clinic - Clinic Visit by Member to RHC/FQHC
0761 Specialty Services - Treatment Room
0920 Other Diagnostic Services - General Classification
0921 Other Diagnostic Services - Peripheral Vascular Lab
0929 Other Diagnostic Services - Other Diagnostic Service
0940 Other Therapeutic Services - General Classification
0960 Professional Fees - General Classification
0981 Professional Fees - Emergency Room Services
0982 Professional Fees - Outpatient Services
0983 Professional Fees - Clinic
N/A

Other Coding Information

Expand All | Collapse All

Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
02/01/2024 R8

Revision Effective: 02/01/2024

Revision Explanation: Annual review, no changes were made. 
11/16/2023 R7

Revision Effective: 11/16/2023

Revision Explanation: Updated LCD Reference Article section.
02/09/2023 R6

Revision Effective: 02/09/2023

Revision Explanation: Annual Review, no changes were made.

 
02/10/2022 R5

Revision Effective: 02/10/2022

Revision Explanation: Annual Review, no changes were made
01/28/2021 R4

Revision Effective: 01/28/2021

Revision Explanation: Annual Review, no changes were made
09/19/2019 R3

Revision Effective: N/A

Revision Explanation: Annual Review, no changes
09/19/2019 R2

R1

Revision Effective: 09/19/2019

Revision Explanation: Converted article into new Billing and Coding template no other changes made.
04/04/2019 R1

Added Group 2 paragraph.
N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L34062 - Dialysis Access Maintenance
Related National Coverage Documents
N/A
SAD Process URL 1
N/A
SAD Process URL 2
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
01/25/2024 02/01/2024 - N/A Currently in Effect You are here
11/08/2023 11/16/2023 - 01/31/2024 Superseded View
01/31/2023 02/09/2023 - 11/15/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

N/A

Read the Article Disclaimer

Submit Feedback/Ask a Question