Treatment of Hand Ischemia Dialysis Associated Steal Syndrome (DASS)

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Treatment of Hand IschemiaDialysis Associated
Steal Syndrome (DASS)

• ASDIN Coding University

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DASS

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

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Ultrasound Evaluation of Vascular Access

• 93990 is the code for ultrasound evaluation of
  the vascular access
• The descriptor for this code is duplex scan of
  hemodialysis access (including arterial inflow,
  body of access and venous outflow)

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Required Elements of Study

• This study must include all components of the
  access
• Arterial inflow
• Body of access
• Venous outflow
• Since the descriptor specifically states duplex
  ultrasound, the study must include
• 2D (B mode) ultrasound to visualize anatomy
• Doppler ultrasound to assess flow
• (See unit of US of Vascular Access for more
  details)

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Arteriogram

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

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Using More Than 1 Modality to Image

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

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Interventional Treatment

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

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Treatment of Upper Arm Access Associated DASS

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

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Treatment of DASS Associated with Forearm Access

• Placing an embolization coil in the distal radial
  artery has been used to treat this problem
• This procedure starts with basic cannulation
  36147
• Done prior to the arteriogram described above
• The additional codes that should be used would
  depend upon the requirements of the procedure

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Selective Catheterization

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

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Embolization Coil Placement

• The occlusion of the distal radial artery is
  generally accomplished using an embolization coil
• The code for the insertion of an embolization
  coil is 37204
• The descriptor for 37204 is - transcatheter
  occlusion or embolization, percutaneous, any
  method, non-central nervous system, non-head or
  neck
• An RSI code goes with this code - 75894
• The descriptor for this code is - transcatheter
  therapy, embolization, any method, radiological
  supervision and interpretation

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Post Coil Placement Angiogram

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

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Use of Diagnostic and Therapeutic RSI Codes
Together

• When a diagnostic RSI code is used in
  association with a therapeutic RSI code, a 59
  modifier should be attached to the former
• In the instance described here there are 2
  diagnostic RSI codes and 1 therapeutic RSI code
  
• The embolization coil placement is a therapeutic
  RSI
• The post-coil angiogram via catheter RSI is
  diagnostic
• The initial arteriogram RSI described earlier is
  also diagnostic
• The diagnostic codes should have a 59 modifier
  attached

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Important Note

• This document is for informational purposes only
  and should serve as a guideline for appropriate
  coding.
• The ultimate responsibility for correct coding
  /documentation remains with the provider of
  service. 
• ASDIN makes no representation, warranty, or
  guarantee that this compilation of information is
  error-free, nor that the use of this guide will
  prevent differences of opinion or disputes with
  CMS or any other carrier.
• ASDIN will bear no responsibility or liability
  for the results or consequences that may grow out
  of the use of this guidance.