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CPT Code: 35500
Procedure: Harvest of upper extremity vein, one segment, for lower extremity bypass procedure
(List separately in addition to code for primary procedure)
Description of Procedure: This code describes the harvest of a single vein segment from the upper
extremity that is later used in a lower extremity bypass procedure. Lower extremity bypasses, especially
bypasses traversing the knee are best performed with autogenous vein tissue. The best choice is the
greater saphenous vein. However, in some patients where a lower extremity vein (greater saphenous or
lesser saphenous vein) is not available, a vein needs to be harvested from the upper extremity. Code
35500 may be used to describe harvesting an arm vein to be used as an autogenous venous conduit in
lower extremity bypasses especially those traversing the knee joint.
Patients requiring distal lower extremity bypasses who have absent or inadequate lower extremity
autogenous veins may require arm vein harvest and therefore the use of this add-on code. This is
estimated to be about 5-10% of total lower extremity bypasses.
This technique has a widespread usage and has been used for many years (more than 25-30 years) as
an alternative to using the saphenous vein as the conduit in cases where the saphenous vein in
unavailable due to prior use.
Upper extremity veins (the cephalic and or the basilic) are usually more difficult to dissect and require the
preparation and draping of a field completely separate from the site of the lower extremity bypass
procedure. In addition, harvesting arm veins may influence the type of anesthesia used. Whereas for
lower extremity bypass procedures performed with a lower extremity vein where an epidural or spinal
anesthesia can be used, bypasses performed with arm vein require general anesthesia or a combination
of epidural and axillary block. Furthermore, upper extremity veins are usually thinner and have more
branches to control, which make their dissection more time consuming.
Intra-service work involved in harvest of the upper extremity vein includes dissection of the overlying skin
and soft tissue for the length of conduit required. There is no “typical” length. Often the incision extends
from shoulder to wrist. Alternatively, a long conduit may be obtained with an incision extending down the
arm over the basilic vein, medial to lateral over the antecubital vein, and then back up the arm over the
cephalic vein. The venous side branches are identified, ligated, and divided. Topical papaverine is
administered to prevent venospasm. Once an adequate length is obtained, the vein is ligated at both
ends and excised. The vein is flushed with heparinized saline, gently distended, and tested for leaks. #70 polypropylene sutures are used to repair leaks, and the surgeon wears ocular loupe magnification to
perform these maneuvers. The vein is transferred to the bypass site of the leg, and the bypass surgery is
completed. Thereafter, attention returns to the arm vein harvest site. Closure entails irrigation, routine
hemostasis maneuvers, suture of the subcutaneous tissue, skin closure with sutures or staples, and
application of a dressing. Although the arm wounds are occasionally problematic, the typical patient has
no postoperative wound problems related to arm vein harvest.
Coding Tips:

As with other CPT “add-on” codes, code 35500 is to be reported in addition to the definitive nonhemodialysis bypass graft (e.g. femoral-popliteal bypass) procedure performed.

The harvest of autogenous from upper extremity veins (the cephalic and or the basilic) is usually
more difficult than from the lower veins since the dissection is more difficult and requires the preparation
and draping of a field completely separate from the site of the lower extremity bypass procedure. In
addition, harvesting arm veins may influence the type of anesthesia used.

Furthermore, upper extremity veins are usually thinner and have more branches to control, which
make their dissection more time consuming. Therefore a new code 35500 was added describing the
harvest of a single upper extremity vein for lower extremity bypass procedures.

Code 35681 identifies 1) the harvest of the vessel from a location separate from the graft site,
and 2) the assimilation of the two components of the composite graft (i.e., the joining of the prosthetic
graft material to the autogenous vein.) As a result, it should be used to identify the harvest of the
autogenous vessel and the creation of the composite graft vein for the grafting procedure. Since code
35681 is an add-on code, it is reported in addition to the appropriate bypass graft code (35501-35587).
Common Therapeutic Indications:
This procedure is usually used in patients who have symptomatic ischemia of the lower extremity
manifested by claudication, rest pain, or tissue loss, when these patients do not have a complete
segment of greater saphenous vein available.
CPT Code: 35646
Procedure: Bypass graft, with other than vein; aortobifemoral
Description of Procedure: A laparotomy is performed under general anesthesia. Following a routine
abdominal exploration, the small bowel is mobilized toward the patient’s right side. The retroperitoneum
is incised, and the aorta is exposed along its entire length from just beyond the renal artery origins to the
aortic bifurcation. Complete circumferential dissection of the proximal aorta is performed in order to place
a vascular cross clamp. The proximal common iliac arteries are exposed in a similar manner, care being
taken to avoid injury to the ureters. The retroperitoneum is elevated over the iliac arteries in the pelvis on
both sides to create tunnels for the graft limbs.
Attention is directed to the groins where incisions are performed over the common femoral arteries. The
soft tissue is dissected until the femoral arteries are encountered. The distal common femoral artery and
proximal superficial and profunda femoral arteries are dissected and isolated bilaterally in a region long
enough to achieve vascular control and perform the graft anastomoses.
A tunnel is completed between the femoral regions on each side and the abdominal cavity. This often
requires ligation of multiple crossing veins. Hemostasis is achieved. Intravenous heparin is administered
for anticoagulation. A bifurcated synthetic graft is passed onto the surgical field. Proximal and distal
vascular control of the aorta is obtained, and cross clamps are placed. An anastomosis is performed
between the aorta and the proximal end of the bifurcated graft. Clamps are removed, and extra sutures
are placed as required to achieve anastomotic hemostasis.
One graft limb is passed through each tunnel between abdomen and groins. The graft is checked to
make sure there are no kinks or twists. Starting on either side first, vascular clamps are placed at the
femoral bifurcation, and an arteriotomy is performed. The graft limb is cut to appropriate length, and an
anastomosis is performed between the graft limb and the femoral artery. Vascular clamps are removed,
and the anastomosis is checked for hemostasis. Additional sutures are placed as required.
The aortic graft limb to the femoral artery anastomosis on the opposite side is performed in the identical
fashion and blood flow is restored. Both the lower extremities are checked to confirm adequate perfusion.
The abdominal cavity is checked once again for hemostasis, and appropriate maneuvers are performed
as needed. The abdomen is irrigated with saline, and the viscera are replaced. The retroperitoneum is
reapproximated to prevent contact between the new aortic graft and the bowels. The laparotomy is
closed. The groin incisions are then closed. Irrigation and inspection is performed for hemostasis. Next,
the subcutaneous tissue is closed in multiple layers, and the skin is stapled or sutured.
CPT Code: 35647
Procedure: Bypass graft, with other than vein; aortofemoral
Description of Procedure: A laparotomy is performed under general anesthesia. Following a routine
abdominal exploration, the small bowel is mobilized towards the patient’s right side. The retroperitoneum
is incised, and the aorta is exposed along its entire length from just beyond the renal artery origins to the
aortic bifurcation. Complete circumferential dissection of the proximal aorta is performed in order to place
a vascular cross clamp. The proximal right common iliac artery is exposed in a similar manner, care
being taken to avoid injury to the ureters. The retroperitoneum is elevated over the right iliac artery to
create a tunnel for the graft limb.
Attention is directed to the right groin where an incision is performed over the common femoral artery.
The soft tissue is dissected until femoral artery is encountered. The distal common femoral, and the
proximal superficial and profunda femoral arteries are dissected at the femoral bifurcation. These are
isolated in a region long enough to achieve vascular control and perform the graft anastomosis.
A tunnel is completed between the femoral region and the abdominal cavity. This oftentimes requires
ligation of multiple crossing veins. Hemostasis is achieved. Intravenous heparin is administered for
anticoagulation. A tubular synthetic graft is passed onto the surgical field. Proximal and distal vascular
control of the aorta is obtained, and cross clamps are placed. An anastomosis is performed between the
aorta and the proximal end of the bifurcated graft. Clamps are removed, and extra sutures are placed as
required to achieve anastomotic hemostasis.
The graft limb is passed through the tunnel created between the abdomen and the groin incision. The
graft is checked to make sure there are no kinks or twists. Vascular clamps are placed at the femoral
bifurcation, and an arteriotomy is performed. The graft limb is cut to appropriate length, and an
anastomosis is performed between the graft and the femoral artery. Vascular claps are removed, and
hemostasis is achieved with additional sutures as required.
CPT Code: 35681
Procedure: Bypass graft; composite, prosthetic and vein (List separately in addition to code for
primary procedure)
Description of Procedure: This code describes performance of a bypass operation of which the conduit
is made out of two segments of different graft material; a segment of autogenous vein and segment of
prosthetic graft taken off the shelf. Such a conduit is usually needed in situations where a segment of
autogenous vein is not available in adequate length to perform an all-autogenous venous tissue bypass.
Such situations occur in patients with previous cardiac procedures, lower extremity bypass procedures, or
in situations where the vein is unsuitable to use due to multiple branching which leads to very small vein
size or due to sclerosis of the vein.
There is no pre-or post-service work. Intra-service work begins with construction of the composite graft.
Appropriately sized synthetic graft material is chosen and brought onto the operative field. The synthetic
graft is cut to match the size requirements.
Fine suture is used to sew the vein and synthetic material. The suture line is tested for hemostasis, and
additional sutures are placed as required. The bypass graft (a separately reportable procedure) is then
completed.
Coding Tips:

CPT code 35681 is an add-on code revised to clarify the differing composition of the bypass graft
placed and to offer a more clear definition that this code is to be used only when prosthetic graft is added
to a vein to form the composite graft.

the code includes harvesting of veins from locations other than locally at the bypass graft site;

the code is only reported in addition to bypass graft codes 35501-35587;

the reporting does not allow for a “stair-step” coding convention, (therefore, only one code should
be reported identifying the number of venous segment(s) harvested;

When more than one venous segment is required to create an appropriate length venous conduit,
the anastomosis of those vessels is included in codes 35681-35683.

With the exception of code 35681, the two sets of codes 35681–35683 and 35501–35587 identify
venous procedures (code 35681 identifies a composite procedure, which involves the use of both venous
material and prosthetic material). Therefore, since the 35501-35587 codes all involve the use of venous
material alone, the codes in 35681-35683 series are used to identify the composite grafting procedures
performed for the specific bypass procedures included in the 35501-35587 series.
Common Therapeutic Indications:
This procedure is used for patients who have symptomatic ischemia of the lower extremity manifested by
claudication, rest pain, or tissue loss, in the absence of a complete segment of greater saphenous vein.
CPT Code: 35682
Procedure: Bypass graft; autogenous composite, two segments of veins from two locations (List
separately in addition to code for primary procedure)
Description of Procedure: This procedure describes the harvest and anastomosis of multiple vein
segments from distant sites for use as arterial bypass graft conduits. This code is intended for use when
the two vein segments are harvested from a limb other than that undergoing bypass.
This code describes the harvesting and anastomosis of two segments of vein from two anatomic sites for
use as an arterial bypass graft conduit. Lower extremity bypasses, especially bypasses traversing the
knee are best done with autogenous vein tissue. The best choice is the greater saphenous vein.
However, in some patients where greater saphenous vein is not available in its entirety, segments of vein
need to be harvested from different locations and anastomosed to each other to obtain a conduit long
enough to be used for the bypass.
This particular procedure requires dissection of two segments of venous tissue. Oftentimes the search for
an extra vein is an unanticipated event that becomes necessary only after the surgeon has spent a
substantial amount of time working with the greater saphenous before making the determination that a
portion of it is inadequate. In addition, the dissection of venous tissue is a time consuming procedure. It
requires making an incision over the area of the vein, its dissection from the surrounding tissue, and the
double ligation and severance of all vein branches. The segment of vein is then removed from its
location. The same technique is repeated in the harvest of a segment of vein from another location. Then
an anastomosis is performed between the two free segments. This, newly created, longer autogenous
venous tissue segment, is used to perform the bypass. Obviously, this procedure requires more work
than placement of a composite bypass made of one segment of vein and a prosthetic bypass graft taken
off the shelf (i.e., code 35681). The prosthetic bypass graft, obviously, does not need to be harvested.
This code requires work in excess of 35681, including identification of the alternate site, re-preparation
and re-drape if required, skin incision, vein identification and exposure, vein branch ligation, harvest site
hemostasis, and harvest site closure.
Prior to this operation, a review of duplex ultrasound or other studies is necessary to determine the best
suitable segments of vein to use for the bypass graft. Also, additional supervision of the positioning,
prepping, and draping of the additional limb or limbs to be used for vein harvest is directly related to this
add-on work. At each additional vein harvest site, the skin and soft tissue are dissected to expose the
vein. Side branches are identified, ligate, and divided. Topical papaverine is often administered to
prevent venospasm. Once adequate length is obtained, the veins are ligated at both ends and excised.
The venous conduits are flushed with heparinized saline, gently distended and tested for leaks. A very
fine polypropylene suture is used to repair the leaks as found, and the surgeon typically employs ocular
loupe magnification to avoid reduction of the lumen by these sutures. In order to form a single long
conduit, the ends of the two segments are beveled, then sutured together, again using very fine suture
and loupe magnification. The anastomosis is tested for leaks, and these are repaired as needed. The
newly constructed conduit is then employed for completion of the bypass graft (a separately billable CPT
procedure). Directly related to this procedure is the achievement of hemostasis in the distant vein harvest
sites, plus subcutaneous and skin closure of these sites, and application of sterile dressings. Wound care
and analgesia required for the additional vein harvest sites also adds to the postoperative work.
Coding Tips:

The code includes harvesting of veins from locations other than locally at the bypass graft site;

The code is only reported in addition to bypass graft codes 35501-35587;

The reporting does not allow for a “stair-step” coding convention, (therefore, only one code should
be reported identifying the number of venous segment(s) harvested;

When more than one venous segment is required to create an appropriate length venous conduit,
the anastomosis of those vessels is included in codes 35681-35683.

With the exception of code 35681, the two sets of codes 35681–35683 and 35501–35587 identify
venous procedures (code 35681 identifies a composite procedure, which involves the use of both venous
material and prosthetic material). Therefore, since the 35501-35587 codes all involve the use of venous
material alone, the codes in 35681-35683 series are used to identify the composite grafting procedures
performed for the specific bypass procedures included in the 35501-35587 series.
CPT Code: 35683
Procedure: Bypass graft; autogenous composite, three or more segments of vein from two or
more locations (List separately in addition to code for primary procedure)
Description of Procedure: CPT code 35683 describes the harvesting and anastomosis of three or
more segments of vein from two or more anatomic sites for use as an arterial bypass graft conduit.
Again, this procedure requires more work since ore than two segments need to be harvested from
different locations and anastomosed together to obtain a conduit of autogenous venous tissue long
enough to perform the bypass. This requires even more work than harvesting two segments of vein.
This procedure is somewhat comparable to the one previously described. However, in this case, three
segments of veins or more are harvested from different locations in the body. Those locations could be
the lesser saphenous vein in the same leg or the opposite leg, segment of vein from the upper extremity,
or segment of greater saphenous vein from the same or the contra-lateral extremity. Two or more
anastomoses are used to connect all the segments together to obtain enough length to perform an allautogenous vein bypass.
Prior to this operation, a review of duplex ultrasound or other studies is necessary to determine the best
suitable segments of vein to use for the bypass graft. Also, additional supervision of the positioning,
prepping, and draping of the additional limb or limbs to be used for vein harvest is directly related to this
add-on work. At each additional vein harvest site, the skin and soft tissue are dissected to expose the
vein. Side branches are identified, ligate, and divided.
Topical papaverine is often administered to prevent venospasm. Once adequate length is obtained, the
veins are ligated at both ends and excised. The venous conduits are flushed with heparinized saline,
gently distended and tested for leaks. A very fine polypropylene suture is used to repair the leaks as
found, and the surgeon typically employs ocular loupe magnification to avoid reduction of the lumen by
these sutures. In order to form a single long conduit, the ends of the two segments are beveled, then
sutured together, again using very fine suture and loupe magnification. The anastomosis is tested for
leaks, and these are repaired as needed.
For 35683, this beveling/anastomosis/testing/ repairing sequence is repeated until all vein segments have
been joined. The newly constructed conduit is then employed for completion of the bypass graft (a
separately billable CPT procedure). Directly related to this procedure is the achievement of hemostasis in
the distant vein harvest sites, plus subcutaneous and skin closure of these sites, and application of sterile
dressings. Wound care and analgesia required for the additional vein harvest sites also adds to the
postoperative work.
Coding Tips:

The code includes harvesting of veins from locations other than locally at the bypass graft site;

The code is only reported in addition to bypass graft codes 35501-35587;

The reporting does not allow for a “stair-step” coding convention, (therefore, only one code should
be reported identifying the number of venous segment(s) harvested;

When more than one venous segment is required to create an appropriate length venous conduit,
the anastomosis of those vessels is included in codes 35681-35683.

With the exception of code 35681, the two sets of codes 35681–35683 and 35501–35587 identify
venous procedures (code 35681 identifies a composite procedure, which involves the use of both venous
material and prosthetic material).
Therefore, since the 35501-35587 codes all involve the use of venous material alone, the codes in 3568135683 series are used to identify the composite grafting procedures performed for the specific bypass
procedures included in the 35501-35587 series.
CPT Code: 35685
Procedure: Placement of vein patch or cuff at distal anastomosis of bypass graft, synthetic conduit (List
separately in addition to code for primary procedure)
Description of Procedure: The surgeon isolates 2 cm more tibial artery than would be required for a
routine distal anastomosis. A skin incision at a distant site is made to harvest vein patch/cuff to find and
isolate 6-8 cm vein, ligate vein branches, ligate inflow and outflow ends of donor vein, and resect donor
vein. The surgeon opens the harvested vein in longitudinal fashion and performs modified distal
anastomosis of bypass graft using harvested vein as patch or cuff. Sutures are placed with 7-0
Polypropylene using loupe magnification, the vein donor site is irrigated, while achieving hemostasis at
the vein donor site. Subcutaneous tissue and skin is closed at the vein donor site.
Coding Tip:
Code 35685 represents placement of an interposition of venous tissue (vein patch or cuff) at the
anastomosis between the synthetic bypass conduit and the involved artery. Source: September 2002
CPT Assistant newsletter, AMA.
CPT Code: 35686
Procedure: Creation of distal arteriovenous fistula during lower extremity bypass surgery (nonhemodialysis) (List separately in addition to code for primary procedure)
Description of Procedure: An extra 3-5 cm of the tibial artery is dissected as well as 3 – 5 cm of the
tibial vein is dissected. The vein branches are ligated, with ligation of the inflow/outflow end of the donor
vein. Occlusion of venous back bleeding is performed by a temporary micro clip. A longitudinal incision
in the vein is performed with a modified distal bypass anastomosis. To include the vein. Sutures are
placed with 7-0 Polypropylene using loupe magnification. The microclip is removed, and the vein donor
site is irrigated, while achieving hemostasis at the vein donor site.
Coding Tip:
Code 35686 describes the use of autogenous vein to create a fistula between the tibial or peroneal artery
and vein at or beyond the distal bypass anastomosis site of the involved artery. Source: September 2002
CPT Assistant newsletter, AMA.
CPT Code: 35875
Procedure: Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula);
Description of Procedure: This procedure involves the removal of a blood clot, or thrombus, from a
venous, in situ venous or arteriovenous bypass graft (see CPT codes 35501–35683). Bypass grafts are
created surgically using synthetic material or the patient’s veins. The physician opens the bypass graft
and uses a balloon Fogarty catheter to remove the thrombus.
In surgery, the graft and the femoral artery were dissected via an incision placed in the femoral area. An
incision was made in the hood of the graft at the femoral anastomosis and a Fogarty balloon catheter was
used to do thrombectomy of the graft. The common femoral artery is patent with brisk arterial inflow. An
intraoperative arteriogram showed that there was progression of arteriosclerotic disease in the popliteal
artery distal to the area of the popliteal anastomosis. This progression of the disease was probably the
cause for the failure of the bypass. Therefore, via a separate incision in the popliteal area, the distal end
of the graft and the popliteal artery were dissected and a jump graft is performed, either with a prosthetic
material or autogenous vein conduit, from the previous dormant femoral-popliteal graft down to the
popliteal artery distal to the area of disease progression. Postoperatively, the patient was evaluated
frequently for adequate circulation in the lower extremity by pulse checks and Doppler signals and ankle
pressures. In addition, the patient was followed closely postoperatively to detect and treat possible
complications such as re-thrombosis of the graft, muscle ischemia leading to compartment syndrome and
renal injury from myoglobinuria, bleeding, or infection.
Code 35875 describes the thrombectomy of arterial or venous bypass placed originally to relieve limb
ischemia or to bypass a venous occlusion (i.e. not an autogenous or non-autogenous hemodialysis graft).
Reporting the distinction between non-hemodialysis versus hemodialysis graft thrombectomy was
necessary because the thrombectomy of an arterial or venous bypass is a more complicated procedure
than thrombectomy of an arterio-venous dialysis access. Therefore, adding the phrase “other than
hemodialysis graft or fistula” will restrict the use of this code as intended.
The thrombectomy procedure described by code 35875 is used for patients with prosthetic graft originally
placed, for example, for limb ischemia, requiring thrombectomy for occlusion and thrombosis.
Coding Tips:

Code 35875 is used for an open thrombectomy of other than a hemodialysis graft or fistula.

See code 36831 for thrombectomy of an autogenous or non-autogenous dialysis graft.

If a thrombectomy is performed on two separate grafts of two different vessels (arteries or veins)
through the same incision, each thrombectomy would be reported separately, despite the fact that access
was through the same incision for both thrombectomies. Modifier –59 (Distinct Procedural Service)
should be appended to the second thrombectomy procedure to indicate that it was performed on a
different anatomic vessel. (Source: CPT Assistant newsletter, April 2000, page 10).
Common Therapeutic Indications: Clotted graft
Devices Commonly Used: N/A
CPT Code: 35876
Procedure: Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula);
with revision of arterial or venous graft
Description of Procedure: The removal of a blood clot, or thrombus, from a venous, in situ venous or
arteriovenous bypass graft with repair (see codes 35901–35907 for removal of an infected graft).
Coding Tips: N/A
Common Therapeutic Indications: Clotted graft
Devices Commonly Used: N/A
CPT Code: 35901
Procedure: Excision of infected graft; neck
Description of Procedure: This procedure involves excising an infected bypass graft or arteriovenous
(A-V) fistula/graft. An A-V fistula/graft is removed when it becomes occluded with a blood clot, or
thrombus, and is also infected. Synthetic material frequently used for grafting is more likely to become
infected than a patient’s natural arteries and veins.
Coding Tips: The types of bypass grafts located in the neck are carotid, carotid-subclavian, subclaviansubclavian, subclavian-axillary, carotid-vertebral, subclavian-vertebral.
Common Therapeutic Indications: N/A
Devices Commonly Used: N/A
CPT Code: 35903
Procedure: Excision of infected graft; extremity
Description of Procedure:
N/A
Coding Tips: The types of bypass grafts located in the extremities are axillary-femoral, axillary-popliteal,
axillary-tibial, bifemoral, axillary-axillary, axillary-femoral-femoral, femoral-femoral, femoral-popliteal,
femoral-anterior tibial, femoral-posterior tibial, femoral-peroneal artery, popliteal-tibial, popliteal-peroneal
artery.
CPT Code: 35905
Procedure: Excision of infected graft; thorax
Description of Procedure:
N/A
Coding Tips: The types of bypass grafts located in the thorax are aortosubclavian, aortocarotid.
CPT Code: 35907
Procedure: Excision of infected graft; abdomen
Description of Procedure:
N/A
Coding Tips: The types of bypass grafts located in the abdomen are aortoceliac, aortomesenteric,
aortorenal, splenorenal, aortoiliac, aortofemoral, aortofemoral-popliteal, ilioiliac, and iliofemoral.
CPT Code: 36002
Procedure: Injection procedures (e.g., thrombin) for percutaneous treatment of extremity
pseudoaneurysm
Description of Procedure: Frequently done as an outpatient procedure, percutaneous injection is used
to treat iatrogenic pseudoaneurysms of the upper and lower extremities. This technique differs markedly
from other therapies used to treat extremity pseudoaneurysms.
The leak is detected by a separately reported duplex examination demonstrating a pseudoaneurysm
arising from the artery. Using imaging guidance for accurate positioning a catheter is introduced into the
pseudoaneurysm, with an attached syringe containing thrombin solution. Small amounts of the thrombin
mixture are injected into the pseudoaneurysm under guidance until total thrombosis of the
pseudoaneurysm is demonstrated.
Common Therapeutic Indications: Iatrogenic pseudoaneurysms may occur following arterial
cannulation for vascular diagnostic and therapeutic procedures. The puncture site in the artery fails to
seal, allowing blood to leak into the surrounding soft tissue. Rather than leaking diffusely through the
tissue, the blood is contained in a mushroom shaped cavity that develops adjacent to the needle hole in
the artery. This cavity is the actual “pseudoaneurysm. Blood rushed from the artery into the
pseudoaneurysm with each systolic heartbeat then flows back from pseudoaneurysm to artery during
diastole. The hematoma is contained or “constrained” by the local tissues which forms a false or
pseudoaneurysm.
Coding Tip: It would not be appropriate to additionally report CPT codes 36000 introduction of needle or
intracatheter, vein and 90782-90799 Therapeutic, prophylactic, or diagnostic injections as these are
integral components of this procedure.
CPT Code: 36260
Procedure: Insertion of implantable intra-arterial infusion pump (e.g., for chemotherapy of liver)
Description of Procedure: This procedure involves the surgical placement of an arterial catheter, into
the hepatic artery of the liver through a surgical incision in the abdomen. It is then brought out and
attached to an infusion pump. The infusion pump, approximately the size of a silver dollar, holds 10 to 15
cc of fluid. The entire pump fits underneath the skin, similar to a pacemaker generator, creating a lump
under the skin at the site. When access to the site is needed to fill the infusion pump, a needle is inserted
into the pump’s reservoir.
Common Therapeutic Indications: Carcinoma of the liver
Devices Commonly Used: Medtronic Synchromed, INFUSAID, CADD
CPT Code: 36261
Procedure: Revision of implanted intra-arterial infusion pump
Description of Procedure: In this procedure, the infusion pump is replaced if it fails or becomes
damaged during refilling; the catheter is replaced if it becomes occluded.
Devices Commonly Used: Medtronic Synchromed, INFUSAID, CADD
CPT Code: 36262
Procedure: Removal of implanted intra-arterial infusion pump
Description of Procedure: The entire infusion pump is removed, usually after several weeks or months,
depending on the patient’s treatment schedule.
Common Therapeutic Indications: Completion of chemotherapy; infected pump or catheter
Devices Commonly Used: Medtronic Synchromed, INFUSAID, CADD
CPT Code: 36420
Procedure: Venipuncture, cutdown; under age 1 year
Description of Procedure: A vein is surgically exposed (cutdown), and a catheter is inserted through a
small incision in the wall of the vein. When large volumes of fluid are needed, the end (adapter) of an
intravenous (IV) tube may be cut off and the IV tubing placed directly into the vein.
Coding Tips: Comments
This is not a central venous line, but a peripheral line that is placed in the arm or leg, most commonly in
the saphenous vein at the ankle.
Common Therapeutic Indications: N/A
Devices Commonly Used: N/A
CPT Codes/Procedures:
36555
Insertion of non-tunneled centrally inserted central venous catheter; under 5 years of age
36556
Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older
36575
Repair of tunneled or non-tunneled central venous access catheter, without
subcutaneous port or pump, central or peripheral insertion site
36580
Replacement, complete, of a non-tunneled centrally inserted central venous catheter,
without subcutaneous port or pump, through same venous access
Description of Procedure: Partially implanted catheters are distinguished from non-tunneled venous
access devices by the technique required to create the “tunnel,” in which the intracutaneous portion of the
catheter lies. During the placement of a non-tunneled central venous catheter, a short tract is developed
as the catheter is advanced from the skin entry site to the point of venous cannulation. During the
insertion of a partially implantable catheter, creating the tunnel requires a specific and separate surgical
step, not simply a skin incision with tract dilation. Only after the tunnel is developed, can the catheter be
passed between the skin entry site and the point of venous cannulation. The length of the subcutaneous
portion of a partially implanted catheter is typically much greater (eg, to reach from below the nipple level
to the subclavicular area) than that of a non-tunneled central venous catheter. (Source: CPT Assistant
newsletter, February1999, page 2).
To qualify as a central venous access catheter or device, the tip of the catheter/device must terminate in
the subclavian, brachiocephalic (innominate) or iliac veins, the superior or inferior vena cava, or the right
atrium.
The venous access device may be central inserted when the jugular, subclavian, femoral vein or inferior
vena cava is the catheter entry site).
For CPT coding, insertion involves the placement of catheter through a newly established venous access.
For CPT coding, replacement is performed if an existing central venous access device is removed and a
new one placed via a separate venous access site, appropriate codes for both procedure (removal of old,
if code exists), and insertion of new device) should be reported.
For CPT coding, repair involves fixing a device without replacement of either catheter or port/pump, other
than pharmacologic or mechanical correction of intracatheter or pericatheter occlusion (see codes 36595
or 36596).
The work required for removal of a non-tunneled central venous access catheter is considered to be
inherent in the evaluation and management visit in which it is performed. (Source: September 2004 CPT
Assistant newsletter, AMA, Chicago, IL).
There is no distinction between venous access achieved percutaneously versus by cutdown or based on
catheter size.
Percutaneous Placement:

The skin is prepped and draped, and a needle (usually 18-gauge, about 3 inches long) with a
syringe attached is placed under the lateral third of the clavicle until blood is drawn into the
syringe (this confirms that the vein has been entered). A wire is then threaded through the
needle, the needle is removed, and a long catheter is threaded over the wire (Seldinger
technique), which guides the catheter. The catheter is then inserted through the skin (a “nick”
may be made next to the wire to enlarge the opening) and into a vein of the thoracic cavity
(usually the subclavian, internal jugular, femoral or antecubital vein).

The catheter must be placed in the thoracic cavity for several reasons: (1) when the
procedure is performed to measure pressure, a more accurate reading is permitted because
no valves are located between the end of the catheter and the heart; (2) when chemotherapy
is being administered, the relatively large blood flow around the end of the catheter dilutes
the drugs, thus minimizing damage to the vein; (3) during hemodialysis, a relatively large
catheter is used for better flow (hemodialysis involves pulling blood back across the dialysis
coil and reusing it), thus requiring that it be placed in a larger vessel.

Percutaneous placement of a catheter may be performed in a hospital ward, in the intensive
care unit or in the operating room, depending on the hospital’s medical policies.

Removal: The suture holding the catheter in place is cut, the catheter is pulled out, and
pressure is held on the site.

Do not report codes 36589 or 36590 for removal of a non-tunneled central venous catheters.

An x-ray is usually performed to confirm the position of the catheter. The catheter should not
be located in the ventricle or in the atrium because it may erode through the heart. In
addition, the catheter tip should not be located so close to the skin that it might come out of
the vein.

Catheters used for children are much smaller (4 to 6 cm in length) than those used for adults
(7 to 12 cm in length). It is usually more difficult to find the appropriate vein in children when
placing a catheter.

Besides their use in chemotherapy, central venous catheters are used for measuring central
venous pressure, for guide-wire insertion before insertion of a Swan-Ganz catheter, for
parenteral nutrition and for procedures performed on patients with poor peripheral veins.
When used intermittently, such as for blood withdrawal, IV fluid administration or medication
administration, a venous catheter may be capped with a plug, filled with heparin and may be
referred to in the medical record as a heparin lock or hep-lock.

Percutaneous placement of a central venous angiocatheter is sometimes performed for
interlipid infusion or hyperalimentation.

Intravenous (parenteral) hyperalimentation is a method of providing total nutrition entirely by
the intravenous route. It involves the infusion of a nutrient solution at a constant rate through
an indwelling catheter usually placed in the superior vena cava. The procedure is used to
provide long-term nutrition to patients whose gastrointestinal function is deranged to the
extent that adequate oral intake is prevented for an extended period of time.

In hemodialysis, blood is removed from the body and pumped through a hemodialysis coil, a
process that removes toxins from the body when the kidneys are not functioning properly.
The “artificial kidney” consists of a synthetic membrane permeable to solutes and water in the
blood. Before a patient can receive hemodialysis, access to the circulation system must be
obtained to allow a high rate of blood flow through the artificial kidney. In emergency
situations, a large catheter, such as a Quinton catheter, may be inserted into either a
subclavian or femoral vein. Such catheters are prone to infection and cannot be left in place
for a long time.

Devices Commonly Used: Groshong, Broviac (used commonly in children), Hickmann,
Intrasil, Centrasil, PPIC, Corcath, Port-A-Cath, Hemocath, PercuCath, Hydrocath, Arrow
multi-lumen, Rauf dual-lumen, triple-lumen, Gambro, Quinton, Cook, Safe-Dwell Plus, and
Shiley. Except for the Broviac and Hickmann catheters, all catheters and reservoirs are
tunneled just under the skin. Central venous catheters do not have reservoirs.

See code 36597 for repositioning of previous placed central venous catheter under
fluoroscopic guidance.
Cutdown Placement:

Cutdown refers to the dissection of a vein for insertion of a cannula or needle for
administration of intravenous fluids or medication. CPT Assistant newsletter, Oct. 1998, p.10.

The skin is prepped and draped, and an incision is made into the skin to expose one of the
veins. The vein is isolated, a small “nick” is made in the vein, and a catheter is inserted
through the opening. The catheter is advanced so that the tip is positioned in the superior
vena cava. This position is confirmed by either fluoroscopy or chest x-ray.

Removal: A small incision is made along the border of the catheter cuff. The cuff is then
dissected free, the catheter tube and cuff are removed, and the skin is closed with two or
three sutures.

In the cutdown technique, the vein is exposed and visualized directly, as opposed to the
percutaneous technique, in which the vein is entered with a needle, without an incision in the
skin. A physician may choose to perform cutdown placement rather than percutaneous
placement of a central venous catheter for several reasons:
-
Multiple percutaneous “sticks” may scar a vessel, and the physician may need to find an
alternative vessel that is not as easy to reach.
-
With very small children, it is more difficult to access their veins percutaneously.

A Hickmann catheter, which has a cuff on it, must be placed via cutdown. A tunnel is made
under the skin, and the Hickmann catheter is then put into the vein, so that the site at which
the catheter enters the skin is a few inches away from where the catheter enters the vein.
The cuff on the catheter is placed in a pocket underneath the skin and acts as a barrier to
infection along the catheter “track.”

Devices Commonly Used: Groshong, Broviac, Hickmann, Hydrocath, Arrow multi-lumen,
Rauf dual-lumen, triple-lumen, Gambro, Quinton, Shiley, Cook, Port-A-Cath, PPIC, Intrasil,
Centrasil, Corcath, Hemocath, PercuCath.
CPT Codes/Procedures:
36563
Insertion of tunneled centrally inserted central venous access device with subcutaneous
pump
36576
Repair of central venous access device, with subcutaneous port or pump, central or
peripheral insertion site
36578
Replacement, catheter only, of central venous access device, with subcutaneous port or
pump, central or peripheral insertion site
36583
Replacement, complete, of a tunneled centrally inserted central venous access device,
with subcutaneous pump, through same venous access
36590
Removal of tunneled central venous access device, with subcutaneous port or pump,
central or peripheral insertion
Description of Procedure: To qualify as a central venous access catheter or device, the tip of the
catheter/device must terminate in the subclavian, brachiocephalix (innominate) or iliac veins, the superior
or inferior vena cava, or the right atrium.
The venous access device may be central inserted when the jugular, subclavian, femoral vein or inferior
vena cava is the catheter entry site).
Insertion of Pump:

A pocket is created under the skin, in the subcutaneous tissues. The pump is inserted into
this pocket, and the attached catheter is inserted into a nearby vein and directed into the
central veins (similar to a central venous catheter). The site is then closed. A pump may
also be placed in the patient’s flank and attached to a catheter that has been inserted into the
spinal or epidural space. A lump will remain at the site at which the pump is located.

One type of implantable infusion pump is a disk-shaped device with two chambers, a side
port and a catheter. One chamber contains the fluid to be infused, while the second chamber
is the charging chamber. It contains a fluorocarbon fluid that expands at body temperature
and exerts pressure on the bellows of the pump, thus forcing the fluid to be infused into the
catheter. The side port provides access for bolus injections, perfusion studies or catheter
flushing. Pump refills and bolus injections are accomplished percutaneously by using a
Huber needle to access the self-sealing ports of entry.

Another type of implantable infusion pump is powered by a lithium battery. It consists of a
refillable reservoir, an electronic control module and a miniature peristaltic pump. A selfsealing septum permits refill or evacuation of the reservoir with a Huber needle. This type of
pump is programmable with a device outside the body, which permits changes in flow rate
after the device is implanted. The INFUSAID is an infusion pump that is subcutaneously
implanted in a lower abdominal quadrant, with the catheters tunneled to the site of infection.
The pump provides a continuous infusion of drugs to the region.

An infusion pump is a device used to provide a continuous infusion of implantable
medications (often narcotics) for managing chronic pain. It is also used for administering
chemotherapeutic agents, such as 5-fluorouracil or colon or liver cancer. Infusion pumps
allow patients to receive some of their treatment at home. The oncologist bases the timing
and dosage of chemotherapeutic agents pumped into the patient on the kind of tumor and the
chemotherapy administered. When the infusion pump reservoir empties, the patient visits the
hospital or ambulatory surgery center on an outpatient basis for a refill.

Devices Commonly Used: Medtronic Synchromed, INFUSAID, CADD
Revision of Pump:

The infusion pump is usually in need of repair due to breakage of the catheter or failure of the
pump. A skin incision is made over the pump, and the pump is dissected free. If the pump
has failed, it is replaced by a new pump. If the catheter is broken, an attempt to repair it is
made or, if this is unsuccessful, a new catheter is inserted. Following replacement of the
pump or repair of the catheter, the skin incision is sutured closed.

Devices Commonly Used: Medtronic Synchromed, INFUSAID, CADD
Removal of Pump:

The infusion pump is removed because the pump is infected or the treatment is completed.
An incision is made over the pump, which is then dissected free from the surrounding tissues
and removed from the pocket. The attached catheter is gently withdrawn, and pressure is
applied to the site at which the catheter entered the vein. Following hemostasis, the incision
is sutured closed and a dressing applied.

Devices Commonly Used: Medtronic Synchromed, INFUSAID, CADD
CPT Codes/Procedures:
36557
Insertion of tunneled centrally inserted central venous catheter, without subcutaneous
port or pump; under 5 years of age
36558
Insertion of tunneled centrally inserted central venous catheter, without subcutaneous
port or pump; age 5 years or older
36565
Insertion of tunneled centrally inserted central venous access device, requiring two
catheters via two separate venous access sites; without subcutaneous port or pump (eg,
Tesio type catheter)
36575
Repair of tunneled or non-tunneled central venous access catheter, without
subcutaneous port or pump, central or peripheral insertion site
36581
Replacement, complete, of a tunneled centrally inserted central venous catheter, without
subcutaneous port or pump, through same venous access
36589
Removal of tunneled central venous catheter, without subcutaneous port or pump
Description of Procedure: Tunneling is the process of passing the catheter under the skin through a
subcutaneous tract. Typically, the dictation will state "the catheter was passed through a subcutaneous
tunnel", or "a subcutaneous tunnel was formed". Technically, it is done by having two skin incision sites,
then passing a "tunneler" under the skin so that the two holes are connected.
To qualify as a central venous access catheter or device, the tip of the catheter/device must terminate in
the subclavian, brachiocephalix (innominate) or iliac veins, the superior or inferior vena cava, or the right
atrium.
The venous access device may be central inserted when the jugular, subclavian, femoral vein or inferior
vena cava is the catheter entry site).
For CPT coding, insertion involves the placement of catheter through a newly established venous access.
For CPT coding, for repair, partial (catheter only) replacement, complete replacement, or removal of both
catheters (placed from separate venous access sites) of a multi-catheter device, with or without
subcutaneous ports/pumps, use the appropriate code describing the service with a frequency of two.
For CPT coding of device replacement, if an existing central venous access device is removed and a new
one placed via a separate venous access site, appropriate codes for both procedure (removal of old, if
code exists), and insertion of new device) should be reported.
CPT Codes/Procedures:
36560
Insertion of tunneled centrally inserted central venous access device, with subcutaneous
port; under 5 years of age
36561
Insertion of tunneled centrally inserted central venous access device, with subcutaneous
port; age 5 years or older
36566
Insertion of tunneled centrally inserted central venous access device, requiring two
catheters via two separate venous access sites; with subcutaneous port(s)
36576
Repair of central venous access device, with subcutaneous port or pump, central or
peripheral insertion site
36578
Replacement, catheter only, of central venous access device, with subcutaneous port or
pump, central or peripheral insertion site
36582
Replacement, complete, of a tunneled centrally inserted central venous access device,
with subcutaneous port, through same venous access
36590
Removal of tunneled central venous access device, with subcutaneous port or pump,
central or peripheral insertion
Description of Procedure: The venous access device may be central inserted when the jugular,
subclavian, femoral vein or inferior vena cava is the catheter entry site).

Venous access ports are also called vascular access devices (VADs); they are implanted
surgically using a local anesthetic. The surgeon creates a subcutaneous pocket to house the
portal. The VAD is usually placed under the pectoral muscles or skin in the anterior chest
below the clavicle. The catheter is inserted into the desired blood vessel. When the port and
catheter are connected, the pocket is closed.

Implantable VADs consist of a reservoir, an inlet septum in the center of the reservoir and a
radiopaque outlet catheter (that is placed into a vein). The inlet septum (soft, center part of
the VAD) is designed to accept multiple punctures from special types of needles (e.g., Huber)
and still maintain its leak-tight integrity. The needle is used to enter the VAD to infuse the
medication or chemotherapy. If a standard hypodermic needle is used, the septum will lose
its leak-tight integrity. A VAD is not a pump, but the VAD port may be inserted with tubing
that is connected to a pump. The entire VAD is self-contained subcutaneously; no part of it is
external.

VADs are unlike infusion pumps in that automatic infusion of chemotherapeutic agents is not
possible. The VAD may be used without the subcutaneous reservoir. Patients with VADs
often visit the hospital or ASC at least once a month for chemotherapy, although the timing
may vary depending upon the kind of tumor being treated.

Completely implanted devices: includes a subcutaneous reservoir with a self-sealing septum,
through which the catheter is permanently accessed by a non-coring needle (eg, Huber,
Angiocath). All portions of a completely implanted device are located beneath the skin.

Partially implanted devices: such as Hickman and Broviac include a visible external site(s)
remote from the venous entry site. External injection/infusion cap(s) lead to the device’s one
or more lumen(s). Partially implanted devices do not have subcutaneous reservoirs. In
addition to the external access site(s), partially implanted devices travel beneath the skin
before entering the vein. Partially implanted catheters are distinguished from non-tunneled
venous access devices by the technique required to create the “tunnel,” in which the
intracutaneous portion of the catheter lies. During the placement of a non-tunneled central
venous catheter a short tract is developed as the catheter is advanced from the skin entry
site to the point of venous cannulation. During the insertion of a partially implantable catheter,
creating the tunnel requires a specific and separate surgical step, not simply a skin incision
with tract dilation. Only after the tunnel is developed, can the catheter be passed between the
skin entry site and the point of venous cannulation. The length of the subcutaneous portion of
a partially implanted catheter is typically much greater (eg, to reach from below the nipple
level to the subclavicular area) than that of a non-tunneled central venous catheter. (Source:
CPT Assistant newsletter, February1999, page 2).

VADs are catheters that provide prolonged vascular access for chemotherapy, intravenous
fluids, medications or the withdrawal of blood for blood sampling. The device typically is
implanted in patients who require long-term access for chemotherapy or for nutritional
purposes. A manufacturer’s identification label on the medical record will verify that a venous
access port and not a central venous catheter (codes 36488–36491) was inserted. The
labels usually contain the following: name of manufacturer, name of device, patient name,
product code, lot number, implant site, implant date and implanting surgeon.

The catheter may need to be replaced if it breaks or detaches from the portal of the VAD. An
x-ray is used to determine these situations. An incision is made over either the VAD, in the
case of a detached catheter, or over the appropriate part of the catheter, if the catheter is
broken. The discontinuity is then repaired, and the skin incision is closed with sutures.

The VAD maybe removed because it is infected or the treatment is completed. An incision is
made over the VAD. The VAD is then dissected free from the surrounding tissues and
removed from the pocket. The attached catheter is gently withdrawn, and pressure is applied
to the site at which the catheter entered the vein. Following hemostasis, the incision is
sutured closed and a dressing applied.

The venous access device may be central inserted when the jugular, subclavian, femoral vein
or inferior vena cava is the catheter entry site).

For CPT coding, insertion involves the placement of catheter through a newly established
venous access.

For CPT coding, for repair, partial (catheter only) replacement, complete replacement, or
removal of both catheters (placed from separate venous access sites) of a multi-catheter
device, with or without subcutaneous ports/pumps, use the appropriate code describing the
service with a frequency of two.

For CPT coding of device replacement, if an existing central venous access device is
removed and a new one placed via a separate venous access site, appropriate codes for
both procedure (removal of old, if code exists), and insertion of new device) should be
reported.

Use code 96530 for the refilling and maintenance of an implantable pump or reservoir.

Devices Commonly Used: Norport, Medtronic, MicroPort, Q-Port, Infuse-a-Port, Dual Port,
Groshong, MacroPort, Button Port, Port-A-Cath, LifePort
CPT Codes/Procedures:
36568
Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous
port or pump; under 5 years of age
36569
Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous
port or pump; age 5 years or older
36570
Insertion of peripherally inserted central venous access device, with subcutaneous port;
under 5 years of age
36571
Insertion of peripherally inserted central venous access device, with subcutaneous port;
age 5 years or older
36575
Repair of tunneled or non-tunneled central venous access catheter, without
subcutaneous port or pump, central or peripheral insertion site
36576
Repair of central venous access device, with subcutaneous port or pump, central or
peripheral insertion site
36578
Replacement, catheter only, of central venous access device, with subcutaneous port or
pump, central or peripheral insertion site
36584
Replacement, complete, of a peripherally inserted central venous catheter (PICC),
without subcutaneous port or pump, through same venous access
36585
Replacement, complete, of a peripherally inserted central venous access device, with
subcutaneous port, through same venous access
36590
Removal of tunneled central venous access device, with subcutaneous port or pump,
central or peripheral insertion
Description of Procedure: To qualify as a central venous access catheter or device, the tip of the
catheter/device must terminate in the subclavian, brachiocephalix (innominate) or iliac veins, the superior
or inferior vena cava, or the right atrium.
The venous access device may be peripherally inserted (eg, basilic or cephalic vein).
For CPT coding, insertion involves the placement of catheter through a newly established venous access.
For CPT coding, replacement is performed if an existing central venous access device is removed and a
new one placed via a separate venous access site, appropriate codes for both procedure (removal of old,
if code exists), and insertion of new device) should be reported.
Coding Tip:

A midline catheter is merely a shorter length version, peripherally inserted, central venous
catheter. Therefore, codes 36568-36569 would be the most appropriate codes to report for a
PICC (midline catheter) line. These codes are selected based upon the specific age described in
the code descriptor. (Source: October 2004 CPT Assistant newsletter, AMA, Chicago, IL).
CPT Codes/Procedures:
36595
Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central
venous device via separate venous access
36596
Mechanical removal of intraluminal (intracatheter) obstructive material from central
venous device through device lumen
Description of Procedure: Advances in device technology have allowed for long-term venous access
for patients undergoing chemotherapy, dialysis, etc. Occasionally, fibrin will collect at the distal end of
these devices or within the lumen. As well, thrombus may form inside the device, thus creating an
obstruction. If an injection of a small amount of a thrombolytic agent is unsuccessful, other interventions
will often allow continued use of the existing device rather than removing and introducing a new device.
This is of far less potential risk and morbidity to the patient. Treatment options include stripping the fibrin
sheath from/about the existing catheter by use of either a transcatheter snare or balloon under imaging
guidance, or alternatively, clearing the intraluminal obstructive material with a guidewire, brush, or other
mechanical device under imaging guidance.
Coding Tip:

Codes 36595 and 36596 have associated radiological supervision and interpretation codes
(75901 for 36595 and 75902 and 36596), which should be separately coded to describe
appropriate imaging guidance and interpretation when such services are performed. It should
also be noted that when these codes are used, related vascular catheterization codes 3601036012 should be separately reported to describe these related component services when
performed.
(Source: December 2004 CPT Assistant newsletter, AMA, Chicago, IL).
CPT Code: 36550
Procedure: Declotting by thrombolytic agent of implanted vascular access device or catheter
Description of Procedure: A thrombolytic agent which is introduced through a syringe and then slowly
instilled into the device or catheter.
Coding Tips:

Use this code to report the declotting of partially or completely implanted devices and catheters.

Do not use this code for routine flushing of vascular access devices with saline or heparin (this
type of flushing is considered inclusive to chemotherapy services and is not reported separately.)
CPT Codes/Procedures:
36568
Insertion of peripherally inserted central venous catheter (PICC),
without subcutaneous port or pump; under 5 years of age
36569
Insertion of peripherally inserted central venous catheter (PICC),
without subcutaneous port or pump; age 5 years or older
Description of Procedure:
The term midline catheter is used by many different individuals to describe different types of peripheral
lines, some terminating in the chest and some in a peripheral vein. More important than the title given to
catheter is the exact anatomic position of the catheter, which can only be determined from careful review
of a well-dictated report.
Depending upon patient’s age, this service should be coded as 36568 (under 5 years of age) or 36569
(age 5 or older). Source: May 2005 CPT Assistant newsletter, AMA, Chicago, IL.
CPT Code:
36598
Procedure: Contrast injection(s) for radiologic evaluation of existing central venous
including fluoroscopy, image documentation and report
access device,
Description of Procedure: The physician performs a quick physical inspection of the catheter site. If
the catheter is not dislodged or kinked, the physician exposes and preps the external port of the catheter
in sterile fashion. Fluoroscopic evaluation of the catheter is performed by the physician, confirming that
the tip of the catheter lies in the central vein as intended and has not migrated into the heart or been
pulled back into a peripheral vein or out of the vein. Fluoroscopy also determines if the catheter has been
fractured or kinked. The physician aspirates the catheter and indwelling anticoagulant is discarded if
possible. Contrast is injected by the physician with imaging of the catheter tip and the vein where the
catheter tip and the vein where the catheter tip is positioned. If necessary, imaging is performed along the
course of the catheter to determine if there is a leak in the catheter. The catheter is flushed with saline
and may be locked with anticoagulant solution. Source: CPT Changes 2006: An Insider’s View, AMA,
Chicago, IL.
Coding Tips




Once imaging is completed, any procedures that are done to try to restore function of the
catheter, if necessary, are coded separately. Source: CPT Changes 2006: An Insider’s View,
AMA, Chicago, IL.
Do not report 36598 in conjunction with 76000.
Do not report 36598 in conjunction with 36595, 36596.
For complete diagnostic studies, see 75820, 75825, 7582 (only for those circumstances where
these structures required a more extensive study).
CPT Code: 36600
Procedure: Arterial puncture, withdrawal of blood for diagnosis
Description of Procedure: In order to draw blood for arterial blood gas analysis, a single, one-time
needle “stick” is performed to an artery, without a device being left in the vessel.
Coding Tips: Comments
This procedure is similar to a venipuncture, except that it involves an artery.
Common Therapeutic Indications: N/A
Devices Commonly Used: N/A
CPT Code: 36620
Procedure: Arterial catheterization or cannulation for sampling, monitoring or transfusion
(separate procedure); percutaneous
Description of Procedure: Catheterization: A 2- or 3-inch catheter is placed percutaneously over a
needle into the artery (usually a brachial, femoral, radial, temporal or posteriotibial artery). The catheter
may be left in place for days (sometimes up to two weeks).
Cannulation: The same type of catheter that is inserted into a vein (intravenous catheter with a needle
enclosed by a sheath) is used. The artery is “stuck” with the needle tip; when blood comes back through
the needle, the catheter is slid off the needle into the artery and left there. The needle is removed, and
the catheter is connected to the transducer or other device.
Common Therapeutic Indications: The arterial catheter is used for monitoring arterial pressures and
withdrawing blood samples for lab studies.
Devices Commonly Used: N/A
CPT Code: 36625
Procedure: Arterial catheterization or cannulation for sampling, monitoring or transfusion
(separate procedure); cutdown
Description of Procedure: A skin incision is made over a peripheral artery (usually radial or dorsalis
pedis), and the artery is dissected free. A 20-gauge needle enclosed in a sheath (catheter) is inserted
directly into the artery; the catheter is then slid off the needle into the artery and the needle is withdrawn.
The catheter is then connected to a transducer for pressure measurement. The skin incision is sutured
closed.
Common Therapeutic Indications: N/A
Devices Commonly Used: N/A
CPT Code: 36640
Procedure: Arterial catheterization for prolonged infusion therapy (chemotherapy), cutdown
Description of Procedure: Placement of the arterial catheter for prolonged infusion therapy may be
performed in one of two ways. (1) A peripheral artery is dissected free and a catheter is inserted into the
artery and threaded, under fluoroscopic or angiographic control, to the site of the tumor. (2) An
abdominal incision is made (for a hepatic tumor); the hepatic artery is isolated and the catheter is inserted
directly into the artery near the liver. The catheter is then brought out through the skin and the incision
closed.
Common Therapeutic Indications: Arterial catheterization delivers chemotherapeutic agents directly
into the blood supply of the tumor in higher doses than the patient normally can tolerate. This method
typically is used with hepatic tumors or metastases to the liver.
Devices Commonly Used: N/A
CPT Code: 36800
Procedure: Insertion of cannula for hemodialysis, other purpose (separate procedure); vein to
vein
Description of Procedure: A cannula (which is a hollow tube) is placed between the two ends of a vein
that has been divided (cut in half). The incision is then closed. No portion of the cannula or vein is
exposed outside the skin. This allows venous access by “sticking” the cannula rather than the vein.
Common Therapeutic Indications: N/A
Devices Commonly Used: N/A
CPT Code: 36810
Procedure: The insertion of cannula Insertion of cannula for hemodialysis, other purpose
(separate procedure); arteriovenous, external (Scribner type)
Description of Procedure: A cannula is placed in the artery and brought out to the skin; the other end of
the cannula is placed into a vein (most common sites are near brachial artery and brachial vein). This
allows the cannula portion of the catheter to lie externally on the skin, and the external portion is available
for access.
Coding Tips: Comments
According to the American Medical Association “code 36815 is reported when a Scribner-type shunt is
revised (i.e., when the shunt fails and the vessel tip must be placed in a different vessel).” The bulk of the
cannula is left in the same site and the tip is connected into another vessel.
Common Therapeutic Indications: This procedure may be used if the patient doesn’t have veins for
direct access or is extremely thin and there is inadequate subcutaneous tissue to appropriately cover a
cannula/shunt. The Scribner-type shunt is a silastic shunt that fits over the vessel tip and is tunneled to a
skin exit site; then it is connected to its mate by another shunt Teflon tube, which can be removed
(opened) to connect to the dialysis tubing.
Devices Commonly Used: Scribner
CPT Code: 36815
Procedure: Insertion of cannula for hemodialysis, other purpose (separate procedure);
arteriovenous, external revision, or closure
Description of Procedure: A revision of an external venous-to-venous cannula typically is performed to
correct infection of the cannula or occlusion by a clot. This is accomplished by replacing the cannula,
resecting the veins or removing the clot. If these procedures are not successful or indicated, the cannula
is removed and the veins ligated.
Common Therapeutic Indications: N/A
Devices Commonly Used: Scribner
CPT Code:
36818
Procedure: Arteriovenous anastomosis, open; by upper arm cephalic vein transposition
Description of Procedure:
This procedure requires two upper arm incisions, one medial over the brachial artery, the other lateral to
expose the vein. A tunnel is created between the incisions, and complete dissection of a substantial
portion of the cephalic vein is required to allow it to be moved to a more superficial location and pulled
through the tunnel for anastomoses with the brachial artery on the medial aspect of the upper arm.
Under unusual situations a patient might undergo 36818 on one upper extremity and a procedure
described by code 36819 (basilica vein transposition), 36820 (forearm vein transposition), 36821 (open
direct arteriovenous anastomosis) or 36830 (nonautogenous graft arteriovenous fistula) on the
contralateral upper extremity. This circumstance would be reported by adding modifier 59 for the second
side (procedure). One indication for the unusual pair of simultaneous operations would be in a procedure
setting in which hemodialysis access is needed in the immediate future, but caregivers hope to avoid a
catheter. A permanent native fistula could be placed in one arm (36818) while a prosthetic hemodialysis
graft is placed in other arm (36830). The shorter-lived prosthetic graft would then be immediately
available for hemodialysis (useable in less than a week if necessary) while allowing 6-8 weeks for the
native fistula to mature.
Code 36818 differs from existing code 36819 in that the procedure described by code 36819 consists of
the basilic vein transposition for brachiobasilic anastomoses.
Code 36818 differs from existing code 36820 in that the procedure described by code 36820 consists of
forearm vein transposition performed in the lower arm between the elbow and the wrist.
Code 36818 differs from existing code 36830 in that the procedure described by code 36830 is the most
commonly performed hemodialysis access operation, and is used to report placement of a synthetic
subcutaneous tube graft in which one end is anastomosed to the brachial artery and the other to a large
vein. This is most often performed when patients do not have large, visible wrist veins for performance of
a native Cimino fistula (36821).
Coding Tips:
 Do not report 36818 in conjunction with 36819, 36820, 36821, 36830 during a unilateral upper
extremity procedures. For bilateral upper extremity open arteriovenous anastomoses performed
at the same operative session, use modifier 50 or 59 as appropriate) .
Common Therapeutic Indications:
This approach is often performed in patients with large or obese arms.
CPT Code: 36819
Procedure: Arteriovenous anastomosis, open; basilic vein transposition
Description of Procedure: Basilic vein transposition entails much more work than placement of a
nonautogenous upper arm graft, since it requires complete dissection of the entire basilic vein from the
antecubital crease up to the axilla. The basilic vein is much deeper in the soft tissue and almost always
has overlying nerves that must be preserved. This procedure requires complete, longitudinal vein
dissection for the entire length of the upper arm, creation of a tunnel, and relocation of the vein into the
new, more superficial location.
Coding Tip:

Do not report 36819 in conjunction with 36818, 36820, 36821, 36830 during a unilateral upper
extremity procedure. For bilateral upper extremity open arteriovenous anastomoses performed at
the same operative session, use modifier 50 or 59 as appropriate)
CPT Code: 36820
Procedure: Arteriovenous anastomosis, open; by forearm vein transposition
Description of Procedure: Code 36820 describes a procedure involving dissection of a long segment of
vein from its site and relocating it to a more superficial or easily accessible position for the purpose of
hemodialysis.
CPT Code: 36821
Procedure: Arteriovenous anastomosis; open direct, any site (e.g., Cimino type) (separate
procedure)
Description of Procedure: The vein is connected directly to the artery without an interposing graft (two
adjacent vessels are connected). This is usually possible when the artery and vein are very close to each
other.
Coding Tips: N/A
Common Therapeutic Indications: N/A
Devices Commonly Used: N/A
CPT Code: 36823
Procedure: Insertion of arterial and venous cannula(s) for isolated extracorporeal circulation including
regional chemotherapy perfusion to an extremity, with or without hyperthermia, with removal of cannula(s)
and repair of arteriotomy venotomy sites
Description of Procedure: This procedure includes calculation and administration of the chemotherapy
agent injected directly into the parfusate. Code 36823 is intended to describe placement of venoarterial
cannulation for chemotherapy perfusion (supported by a membrane oxygenate/perfusion device) to an
isolated region of an extremity to treat a neoplastic process.
Coding Tips:

36823 Includes chemotherapy perfusion supported by a membrane oxygenator/perfusion pump.

Do not report 96408-96425 in conjunction with 36823
CPT Code: 36825
Procedure: Creation of arteriovenous fistula by other than direct arteriovenous anastomosis
(separate procedure); autogenous graft
Description of Procedure: Arteriovenous anastomosis between two vessels using an interposing graft
made of the patient’s natural vein (autogenous). For chronic hemodialysis, vascular access usually
requires the surgical construction of an arteriovenous (A-V) fistula between the patient’s artery and vein,
most often in the forearm. The fistula “matures” in four to six weeks, and increased blood flow causes the
venous site to become enlarged.
Coding Tips: Comments
Although less problematic than external catheters, both fistulas and grafts are prone to infection and
blood clotting.
CPT Code: 36830
Procedure: Creation of arteriovenous fistula by other than direct arteriovenous anastomosis
(separate procedure); nonautogenous graft
Description of Procedure: Arteriovenous anastomosis between two vessels using a synthetic material
as an interposing graft (nonautogenous). A nonautogenous A-V fistula/graft is a tube made from Gortex,
polytetrafluoroethylene (PTFE) or similar biocompatible material. The tube is surgically tunneled under
the skin in a loop that connects an artery to a vein.
Coding Tips: Comments
*
See code 36825.
*
See codes 35501–35683 for creation of bypass grafts.
Common Therapeutic Indications: The artery and vein are far enough apart that they cannot be
directly anastomosed, so a graft material must be used to connect them.
Devices Commonly Used: Gortex
CPT Code: 36831
Procedure: Thrombectomy, open, arteriovenous fistula without revision, autogenous or non
autogenous dialysis graft (separate procedure)
Description of Procedure: In these procedures, when arteriovenous fistulae placed for dialysis (made
of autogenous vein or non-autogenous prosthetic graft material) thrombose, thrombectomy procedures
are needed in order to dialysis (made of autogenous vein or non-autogenous prosthetic graft material)
thrombose, thrombectomy procedures are needed in order to maintain hemodialysis. After the
thrombectomy, revision of the graft may or may not be required. The nomenclature of code 36831
delineates thrombectomy where graft revision is not performed.
Thrombectomy: The fistula/graft is opened, a catheter (e.g., Fogarty) is inserted into the fistula and the
clots are extracted.
The most common site for these arteriovenous dialysis grafts is the forearm or upper arm. At operation,
circumferential exposure of the venous outflow end of the graft is obtained by dissection through typically
scarred tissue. Systemic anti-coagulation is administered, and vascular occluding clamps are placed. An
incision is made in the hood of the graft, and a thrombus filled lumen is encountered. Fogarty balloon
thrombectomy catheters are passed repeatedly in the proximal and distal directions until forceful arterial
inflow and adequate venous backbleeding are obtained. The graft opening is closed using fine vascular
suture, often under ocular loupe magnification. An operative angiogram is frequently obtained to
determine the etiology of graft failure by injecting contrast material while making a single x-ray exposure
or using digital subtraction fluoroscopy.
The most common pathology found in this situation is severe intimal hyperplasia in the outflow vein, but
occasionally, no contributory pathology is found. This is likely to be the case if the patient has suffered a
recent episode of hypotension. If the angiogram reveals no identifiable problems, blood flow through the
dialysis graft and to the hand beyond the graft is evaluated once more for adequacy. If satisfactory, the
wounds are closed in layers.
Coding Tips: With exception of the unlikely circumstances that a patient has two different dialysis grafts
that the surgeon operated on during the same surgical event, codes 36831 , 36832, and 36833 are
generally not reported together (i.e., they are not used to describe procedures performed on the same
graft). If two different dialysis grafts are being addressed, then the appropriate codes for the procedure
performed should be used with the modifier –59 appended to the second procedure performed to identify
it as a distinct procedural service.
CPT Code: 36832
Procedure: Revision, open, arteriovenous fistula; without thrombectomy, autogenous or
nonautogenous dialysis graft (separate procedure)
Description of Procedure: The most common site for these arteriovenous dialysis grafts is in the
forearm or upper arm. The pathology usually encountered is venous hyperplasia along the outflow track
of the graft, causing a severe stenosis, reduction of blood flow through the graft, ineffective dialysis, and
eventual graft thrombosis, if treatment is not undertaken. At operation, circumferential exposure of the
venous outflow end of the graft and adjacent outflow veins is obtained by dissection through typically
scarred tissue. Systemic anti-coagulation is administered, and vascular occluding clamps are placed. An
incision is made in the hood of the graft at the anastomosis and extended across the venous stenosis
until vein of normal caliber is encountered. A long synthetic patch is sewn as a “patch angioplasty” along
the length of the arteriotomy, often using ocular loupe magnification. The graft and outflow vein are
flushed with blood to remove loose debris and air, then blood flow is re-established, and hemostasis
achieved. Blood flow through the dialysis graft and to the hand beyond the graft is evaluated for
adequacy. Once satisfactory flow is obtained, the wounds are closed in layers.
Revision: The fistula/graft site is opened in order to straighten a kink or remove a clot and reanastomose the graft.

According to the AMA, assign code 36832 if an angioplasty is performed on an A-V fistula.
Blood flow through the dialysis graft and to the hand beyond the graft is evaluated for adequacy. Once
satisfactory flow is obtained, the wounds are closed in layers.
Coding Tips: Comments
A clotted A-V access site often can be salvaged by surgical thrombectomy; many infections can be cured
with antibiotics. In some cases, however, infection or thrombosis may necessitate construction of new
vascular access.

See codes 34001–34490 for excision of an acquired traumatic thrombus or congenital thrombus
of an artery or vein.

See codes 35180–35190 for repair of a congenital or acquired traumatic arteriovenous fistula.

See codes 35201–35286 for repair of a blood vessel, other than for fistula.

See codes 35301–35381 for thromboendarterectomy of a vein or artery.

Do not assign code 36145 (introduction of needle or intracatheter; arteriovenous shunt created for
dialysis [cannula, fistula or graft]) for creation or revision of an A-V graft/cannula/ fistula. This code is
assigned only when an angiography of an A-V shunt (shuntogram) is performed; it describes the
surgical/technical component of the procedure. Code 75790 should be assigned to report the
professional component of this interventional radiology (i.e., shuntogram) procedure.

With the exception of the unlikely circumstances that a patient has two different dialysis grafts
that the surgeon operated on during the same surgical event, codes 36831, 36832, and 36833 are
generally not reported together (i.e., they are not used to describe procedures performed on the same
graft). If two different dialysis grafts are being addressed, then the appropriate codes for the procedure
performed should be used with the modifier –59 appended to the second procedure performed to identify
it as a distinct procedural service.
Common Therapeutic Indications: The A-V fistula/graft is kinked, or there is a possibility that the
body’s endothelium will “grow” into the fistula/graft and act as a thrombus, which will cause poor blood
flow in the fistula/graft. Another indication is that the site of the fistula/graft may begin to “scar down” and
become stenosed; this reduces the blood flow. Other problems include failure of maturation
(approximately four to six weeks is needed for the vein to respond to increased flow by enlargement and
mural thickening; shunts formed by grafts can be used earlier, and no maturation is necessary). In
addition, infection, pseudoaneurysm formation and vascular “steal” may develop. Vascular steal involves
the diversion of blood flow from the distal extremity through a shunt, which causes pain and ischemia.
Vascular steal commonly results from a shunt/fistula that is too large. (The incidence of vascular steal is
decreasing due to the introduction of tapered grafts.)
Devices Commonly Used: Fogarty catheter (for thrombectomy)
CPT Code: 36833
Procedure: Revision, open, arteriovenous fistula; with thrombectomy, autogenous or
nonautogenous dialysis graft dialysis graft (separate procedure)
Description of Procedure: For those instances wherein both arteriovenous fistula revision and
thrombectomy is performed, code 36833 reported to more accurately report the additional physician work
involved.
The most common site for these arteriovenous dialysis grafts is in the forearm or upper arm. An
operation, circumferential exposure of the venous outflow end of the graft is obtained by dissection
through typically scarred tissue. Systemic anticoagulation is administered, and vascular occluding
clamps are placed. An incision is made in the hood for the graft, and a thrombus-filled lumen is
encountered. Fogarty balloon thrombectomy catheters are passed repeatedly in the proximal and distal
directions until forceful arterial inflow and adequate venous backbleeding are obtained. The graft opening
is closed using fine vascular suture under ocular loupe magnification. An operative angiogram is
obtained to determine the etiology of graft failure by injecting contrast material while making a single x-ray
exposure or using digital subtraction fluoroscopy.
The most common pathology found in this situation is severe intimal hyperplasia in the outflow vein,
although arterial stenosis or failure of the conduit itself are other typical findings. If venous outflow
hyperplasia if found, vascular occluding clamps are replaced, the distal-most portion of the dialysis graft is
opened, and the incision is carried across the vein stenosis and extended until normal caliber vein is
encountered. A long synthetic patch is sewn as a “patch angioplasty” along the length of the arteriotomy,
using ocular loupe magnification. The graft and outflow vein are flushed with blood to remove loose
debris and air, then blood flow is re-established, and hemostasis achieved. Blood flow through the
dialysis graft and to the hand behind the graft is evaluated for adequacy. Once satisfactory flow is
obtained, the wounds are closed in layers. If other causes of graft thrombosis are found, they are dealt
with as required.
Thrombectomy: The fistula/graft is opened, a catheter (e.g., Fogarty) is inserted into the fistula and the
clots are extracted.
Revision: The fistula/graft site is opened in order to straighten a kink or remove a clot and reanastomose the graft.
Coding Tips: With the exception of the unlikely circumstances that a patient has two different dialysis
grafts that the surgeon operated on during the same surgical event, codes 36831, 36832, and 36833 are
generally not reported together (i.e., they are not used to describe procedures performed on the same
graft). If two different dialysis grafts are being addressed, then the appropriate codes for the procedure
performed should be used with the modifier If two different dialysis grafts are being addressed, then the
appropriate codes for the procedure performed should be used with the modifier 59 appended to the
second procedure performed to identify it as a distinct procedural service.
CPT Code: 36834
Procedure: Plastic repair of arteriovenous aneurysm (separate procedure)
Description of Procedure: An aneurysm results when a weakness develops in the wall of a blood
vessel due to trauma or repeated punctures (needle sticks). Significant dilation may cause a radial artery
aneurysm to fistulize to a vein located next to it. The dilation or weak vessel may be resected.
Coding Tips: Comments
If there is no dilation, and there is a small hole or communication between the artery and the vein, a
ligation of the fistula or resection of the vessels is necessitated.
Coding Tip: Assign this code for the repair of an aneurysm in a direct anastomosis arteriovenous fistula
(i.e., a fistula without an interposing graft). Assign code 36832 or 36832 for the repair of an aneurysm in
an arteriovenous fistula with an interposing graft.
Common Therapeutic Indications: N/A
Devices Commonly Used: N/A
CPT Code: 36838
Procedure: Distal revascularization and interval ligation (DRIL), upper extremity hemodialysis
access (steal syndrome)
Description of Procedure: DRIL does not involve any surgical manipulation of the access itself. The
DRIL procedure addresses this issue as a two-step procedure. The surgeon begins by placing a bypass
graft in the involved arm. The proximal anastomosis of the bypass is placed closer to the axilla than the
dialysis access origin. The distal anastomosis of this bypass extends onto the forearm, beyond the
dialysis access. This part is the “distal revascularization,” and in essence it allows diversion of a strong
blood flow stream around the dialysis access without altering that access. Once completed, the second
step, “interval ligation,” consists of tying off the brachial artery at a site between the dialysis access and
the distal anastomosis of the new bypass. This step prevents blood flow traveling through the new
bypass to the forearm from turning retrograde in the brachial artery and entering the dialysis access. In
essence, the DRIL works by allowing arterial blood flow coming from the heart to enter the DRIL bypass
before it reaches the origin of the hemodialysis access. The DRIL forces the arm’s blood flow to be
shared between the dialysis access and the hand.
The goal of DRIL is to save the hand and preserve the dialysis access and to not waste an access site.
To simple ligate or disconnect the dialysis access will return the anatomy to its native status, but it will
leave the patient without permanent hemodialysis access. If the steal syndrome occurs in one upper
extremity, it is likely that it will occur on the opposite side as well, due to the vascular anatomy of the
individual. Therefore, ligation is not considered a major clinical victory.
Coding Tips/Comments:
Common Therapeutic Indications: Distal revascularization and interval ligation (DRIL) is a procedure
performed for the treatment of steal syndrome, a condition that occurs in a small portion of patients who
have undergone upper extremity hemodialysis access operations, to provide reliable permanent
indwelling needle access for long-term hemodialysis. A small percentage of patients who have
undergone the operation to create the hemodialysis access develop ischemic hand pain postoperatively.
In these cases, the patient’s new hemodialysis access takes virtually all of the arm’s blood flow, leaving
the hand starving for blood and oxygen.
Devices Commonly Used: N/A.
CPT Code: 36860
Procedure: External cannula declotting (separate procedure); without balloon catheter
Description of Procedure: After the cannula is opened, it may be squeezed or “milked” with the fingers
to remove the clot; or the cannula may be flushed to remove the clot. This technique may be used on
internal or external cannulas; is a type of triple-lumen Ligation - Occlusion of the lumen of a vessel by
application of a suture ligature that cuts off the flow in the vessel and causes it to clot; central line having
“external” ports. These do not require “open” incisional techniques to remove the clots.
Code 36860 classifies A “nick” is made in or proximal to the cannula; the balloon (Fogarty) catheter is
inserted into the cannula through the nick, blown up and then pulled back to pull out or extract the clot;
thrombectomy performed on external types of dialysis devices (e.g., Scribner, Hickman, Quentin). This
revision differentiates between open thrombectomy procedures reported by the new code 36831.
Coding Tips: Comments
Clot: Coagulation of blood within the cannula.
Thrombus: An organized clot is present in the A-V fistula/graft for a long period of time and that may
have embolized from another site.
* Codes 36860 and 36861 contain the phrase “external,” thus precluding the reporting of these codes for
percutaneous thrombectomy because dialysis grafts/fistulae are entirely subcutaneous. Source: CPT
Changes 2001: An Insider’s View, AMA.
Common Therapeutic Indications: N/A
Devices Commonly Used: N/A
CPT Code: 36861
Procedure: External cannula declotting (separate procedure); with balloon catheter
Description of Procedure: A “nick” is made in or proximal to the cannula; the balloon (Fogarty) catheter
is inserted into the cannula through the nick, blown up and then pulled back to pull out or extract the clot.
Coding Tips:

If the operative report describes A-V fistula/graft revision and/or thrombectomy, see code 36831–
36833.

Codes 36860 and 36861 contain the phrase “external,” thus precluding the reporting of these
codes for percutaneous thrombectomy because dialysis grafts/fistulae are entirely subcutaneous.
Source: CPT Changes 2001: An Insider’s View, AMA.
Common Therapeutic Indications: N/A
Devices Commonly Used: N/A
CPT Code: 36870
Procedure: Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous
graft (includes mechanical thrombus extraction and intra-graft thrombolysis)
Description of Procedure: The thrombus may be removed from the graft in a variety of methods.
Heparin may be given systemically; thrombolytic drugs may be given into the graft, either as a bolus, as
an infusion, or using a pulsed-spray technique. A limited dose of thrombolytic agent may be instilled into
the thrombus for initiation of thrombolysis. The thrombus may also be mechanically removed with a
variety of specially-designed devices or with Fogarty-type angioplasty-type balloons. The thrombus is
then macerated and the shunt cleared.
Once the maneuvers to remove the thrombus have been completed, repeat fistulography is performed to
verify flow and to evaluate the graft for underlying problems which may have caused the hemodynamic
lesion. Any hemodynamic lesions found are treated (e.g., with balloon angioplasty or occasionally with
stent placement, both of which are coded separately from the declotting procedure itself).
Code 36870 is designed to cover any of these methods or combinations of these methods, and is used
only to describe the actual procedure of removing thrombus from the access and restoring flow. When
these accesses thrombose, most develop what is termed an “arterial plug,” or a small densely fibrotic clot,
at the arterial anastomosis, that typically will not dissolve and which usually sticks in the graft, narrowing
or occluding the arterial inflow. This code also describes removal of this portion of the thrombus, which
usually requires an additional step for removal separate from the rest of the procedure to declot the graft.
Pharmaceutical thrombolysis: the thrombosed graft is typically accessed using one or two catheters or
intracathers to allow instillation of a thrombolytic drug directly into the thrombus. The drug may be
delivered in a bolus, as “pulse spray” with manual bursts of drug delivered through a catheter, or as an
infusion through a catheter. Pharmaceutical thrombolysis typically dissolves the majority of the thrombus.
The rest is treated using mechanical means such as balloon inflation to compress or dislodge the
thrombus. The arterial plug is typically removed by partially inflating a balloon at the arterial anastomosis
and pulling the balloon into the graft, which pulls the arterial plug into the graft. The plug is then further
treated with maceration or dislodgement from the graft.
Mechanical thrombolysis: the thrombosed graft is typically accessed with direct puncture. Sheaths are
placed into the graft to facilitate introduction of the thrombectomy device and the device is activated and
passed through the thrombus until the thrombus is macerated and/or removed. Mechanical thrombolysis
may also be accomplished without use of devices made specifically for this purpose. Small Fogarty-type
balloons are another example of a type of device that may be used for this purpose.
Coding Tips:
 Do not report 36550 in conjunction with code 36870. 36550 classifies thrombolytic agent declotting of
implanted VAD or catheter.
* Punctures into the graft to allow access to both anastomoses is coded with 36145 and should be coded
twice (e.g. 36145, 36145-59) if two separate punctures are performed.
* Report 75790 for diagnostic fistulogram imaging.

Assign 35476 and 75978 for a venous anastomotic stenosis treated with balloon angioplasty to
restore patency and flow.

Assign a single venous angioplasty code, if there is treatment of multiple venous stenoses clumped in
the same vessel.

If a separate vessel from the initially treated stenotic vessel is involved, such as the subclavian vein,
percutaneous transluminal angioplasty (PTA) of that lesion should be coded as a second venous
angioplasty (i.e., 35476, 75978, 35476-59, 75978-59). The modifier –59 is used to delineate the
treatment of a separate vessel.

Assign code 37205 and 75960 for stent placement which may be required in some cases to salvage a
failing access or to treat an acute vessel rupture following venous PTA.

Arterial stenosis, either at the arterial anastomosis or in the inflow vessels, is not commonly found,
but may be present and may be the flow-limiting cause of acute thrombosis of the graft. Angioplasty
of these types of lesions would be coded with braciocephalic angioplasty codes 35475 and 75962 in
upper extremity accesses. If the access is in the leg, 35474 and 75962 for femoral artery PTA or
35473 and 75962 for the iliac artery would be the appropriate codes to describe the procedure.
*
If thrombus is present outside the graft and requires transcatheter thrombolytic therapy (e.g.
thrombus extending into the outflow veins or embolized into a distal artery), this portion of the procedure
would be separately coded as 37201 and 75896 plus the appropriate catheterization code(s). This
therapy typically includes selection of the vessel involved, negotiation of an infusion catheter into the
thrombus and infusion of a drug to dissolve the clot.

Services, not included in 36870, that should be separately reported if additionally performed are: (1)
catheterization (CPT code 36145), (2) angioplasty of the graft/fistula, venous, or arterial anastomoses
(CPT code 35473 - 35476; 75962, 75964, 75978), (3) stenting (CPT codes 37205, 37206, 75960), (4)
fistulography (CPT code 75790), and (5) thrombolytic infusion over one hour in length (CPT codes
37201, 75896. Code 75790 would be reported once for all imaging services directly related to the
initial procedure (e.g., fistulography). Note: Follow-up imaging studies performed either at a different
session on the same day or on a separate day are separately reportable. Source: CPT Changes
2001: An Insider’s View, AMA.
Common Therapeutic Indications: N/A
Devices Commonly Used: N/A
CPT Codes/Procedures:
37184 Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial
bypass graft, including fluoroscopic
guidance and intraprocedural pharmacological
thrombolytic injection(s); initial vessel
37185
Primary percutaneous transluminal mechanical thrombectomy,
noncoronary, arterial or arterial bypass graft, including fluoroscopic
guidance
and intraprocedural pharmacological
thrombolytic injection(s);
second and all subsequent vessel(s) within the
same vascular family (List separately in
addition to code for primary
mechanical thrombectomy procedure)
Description of Procedure:
Mechanical thrombectomy is the removal of thrombus (blood clot) from a vessel for restoration of
circulation, using a unique method of fragmenting and/or removing clots from the peripheral vessel.
Mechanical thrombectomy is performed using devices specific for mechanically breaking up, macerating,
and/or removing thrombus from a vessel. Mechanical thrombectomy may also partially break up (debulk)
a clot prior to thrombolytic infusion, therapy, increasing the surface area upon which a lytic drug may
directly act, thereby reducing the time of treatment and the overall dose of drug required to break up the
thrombus.
Therefore, mechanical thrombectomy is occasionally performed in addition to pharmacological
thrombolysis for restoration of flow to the vessel occluded or compromised by thrombus in certain clinical
circumstances (eg, extensive residual thrombus over a significant vessel length) and is frequently used as
a “debulking” procedure, particularly in veins. If mechanical thrombectomy is done in conjunction with
pharmacological thrombolysis, the catheters used for lysis are generally positioned through percutaneous
access(s) previously established for mechanical thrombectomy directly into the thrombus for institution of
pharmacologic thrombolytic therapy. Pharmacological thrombolysis may be more rapidly and extensively
affective if a large portion of the thrombus has been mechanically removed prior to the institution of
thrombolysis. Pharmacologic thrombolysis, reported with code 37201, is performed by direct delivery of a
thrombolytic drug into the thrombus. Source: CPT Changes 2006: An Insider’s View, AMA, Chicago, IL.
Coding Tips:
Source - CPT Changes 2006: An Insider’s View, AMA, Chicago, IL:

There are instances where other therapeutic procedures are provided in conjunction with
mechanical thrombectomy. For example, after removal of a thrombus from a vessel with
mechanical thrombectomy, an underlying atherosclerotic stenosis is revealed. In such a case,
PTA would be performed and reported as a separate component of work because it is a different
procedure for treatment of a different pathology.

When performed in conjunction with pharmacologic thrombolysis, the necessary catheter
exchange during thrombolytic therapy, which may last for several hours or days, is separately
reportable (37209). Catheter exchanges are done during thrombolysis to “chase” the thrombus
(i.e., to position the catheter so that the lytic dose is directed precisely into the thrombus, and this
target may change as the thrombus lyses) or, if the indwelling infusion catheter is dislodged
during the therapy, prevent delivery of the drug directly into the thrombus. Catheter exchanges
are variably necessary for these procedures and require additional trips to the interventional suite,
often on different days. Therefore, this service is separately reportable.

Do not report 37184 in conjunction with 76000, 76001, 90774, 99143-99150.

Do not report 37185 in conjunction with 76000, 76001, 90775.
CPT Code:
37186
Procedure:
Secondary percutaneous transluminal thrombectomy (eg, nonprimary
mechanical, snare basket, suction technique), noncoronary, arterial or
bypass graft, including fluoroscopic guidance and intraprocedural
pharmacological thrombolytic injections, provided in conjunction with
percutaneous intervention other than primary mechanical
(List separately in addition to code for primary procedure)
arterial
another
thrombectomy
Description of Procedure:
This procedure, also commonly referred to as “rescue” mechanical thrombectomy, is always
performed in conjunction with another percutaneous intervention (eg, percutaneous transluminal balloon
angioplasty, stent placement). These circumstances include those in which a small amount of clot is
present in the lesion and needs to be removed prior to percutanesous transluminal angioplasty
(PTA)/stent or the thrombus/embolus has complicated a PTA/stent procedure, requiring removal of the
thrombus/embolus to complete the procedure. Source: CPT Changes 2006: An Insider’s View, AMA,
Chicago, IL.
Coding Tips

Do not report 37186 in conjunction with 76000, 76001, 90775
CPT Codes/Procedures:
37187 Percutaneous transluminal mechanical thrombectomy, vein(s),
including intraprocedural
pharmacological thrombolytic injections and
fluoroscopic guidance
37188 Percutaneous transluminal mechanical thrombectomy, vein(s),
including intraprocedural
pharmacological thrombolytic injections and
fluoroscopic guidance, repeat treatment on
subsequent day during course of thrombolytic therapy
Description of Procedure:
Mechanical thrombectomy is the removal of thrombus (blood clot) from a vessel for restoration of
circulation, using a unique method of fragmenting and/or removing clots from the peripheral vessel.
Mechanical thrombectomy is performed using devices specific for mechanically breaking up, macerating,
and/or removing thrombus from a vessel. Mechanical thrombectomy may also partially break up (debulk)
a clot prior to thrombolytic infusion, therapy, increasing the surface area upon which a lytic drug may
directly act, thereby reducing the time of treatment and the overall dose of drug required to break up the
thrombus.
Therefore, mechanical thrombectomy is occasionally performed in addition to pharmacological
thrombolysis for restoration of flow to the vessel occluded or compromised by thrombus in certain clinical
circumstances (eg, extensive residual thrombus over a significant vessel length) and is frequently used as
a “debulking” procedure, particularly in veins. If mechanical thrombectomy is done in conjunction with
pharmacological thrombolysis, the catheters used for lysis are generally positioned through percutaneous
access(s) previously established for mechanical thrombectomy directly into the thrombus for institution of
pharmacologic thrombolytic therapy. Pharmacological thrombolysis may be more rapidly and extensively
affective if a large portion of the thrombus has been mechanically removed prior to the institution of
thrombolysis. Pharmacologic thrombolysis, reported with code 37201, is performed by direct delivery of a
thrombolytic drug into the thrombus. Source: CPT Changes 2006: An Insider’s View, AMA, Chicago, IL.
Coding Tips:
Source - CPT Changes 2006: An Insider’s View, AMA, Chicago, IL:

There are instances where other therapeutic procedures are provided in conjunction with
mechanical thrombectomy. For example, after removal of a thrombus from a vessel with
mechanical thrombectomy, an underlying atherosclerotic stenosis is revealed. In such a case,
PTA would be performed and reported as a separate component of work because it is a different
procedure for treatment of a different pathology.

When performed in conjunction with pharmacologic thrombolysis, the necessary catheter
exchange during thrombolytic therapy, which may last for several hours or days, is separately
reportable (37209). Catheter exchanges are done during thrombolysis to “chase” the thrombus
(i.e., to position the catheter so that the lytic dose is directed precisely into the thrombus, and this
target may change as the thrombus lyses) or, if the indwelling infusion catheter is dislodged
during the therapy, prevent delivery of the drug directly into the thrombus. Catheter exchanges
are variably necessary for these procedures and require additional trips to the interventional suite,
often on different days. Therefore, this service is separately reportable.

Do not report 37187 in conjunction with 76000, 76001, 90775
Do not report 37188 in conjunction with 76000, 76001, 90775
CPT Code: 37607
Procedure: Ligation or banding of angioaccess arteriovenous fistula
Description of Procedure: Ligation - Occlusion of the lumen of a vessel by application of a suture
ligature that cuts off the flow in the vessel and causes it to clot.
Banding - Wrapping of an AV fistula, usually with synthetic material, in order to reduce blood flow from
any outside source.
Common Therapeutic Indications: N/A
Devices Commonly Used: N/A
Sources: Burton Briggs, MD, Loma Linda University Medical Center, Loma Linda, Calif.; Coding Clinic
for ICD-9-CM, Third Quarter 1991, page 13; American Hospital Association, Chicago, Ill; Coding Clinic
for ICD-9-CM, Fourth Quarter 1990, page 5; American Hospital Association, Chicago, Ill; and Books in
Radiology: Interventional Radiology and Angiography, Myron Wojtowycz, MD, Year Book Medical
Publishers, Inc., 1990; CPT Assistant, fall 1993, pages 4–6, American Medical Association; CPT 1999
Coding Symposium, Nov. 11-13, 1998, Chicago—presenters: Robert Zwolak, MD, associate professor of
surgery at Dartmouth Medical School and attending vascular surgeon at the Mary Hitchcock Memorial
Hospital in Hanover, New Hampshire, and medical director of the noninvasive vascular laboratory at the
Dartmouth-Hitchcock Medical Center; CPT 2002Code Book, American Medical Association, Chicago, IL,
2000; CPT Assistant newsletter, November, 1998, American Medical Association, Chicago, IL, 1998; CPT
Assistant newsletter, November 1999, American Medical Association, Chicago, IL 1999; CPT Assistant
newsletter, May 2001, American Medical Association, Chicago, IL, 2001; CPT 2002: An Insider’s View,
AMA; CPT Changes 2004: An Insider’s View, AMA; Source: CPT Changes: An Insider’s View 2005, AMA,
Chicago, IL, 2004).