Treatment of Hand Ischemia
Dialysis 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 RS&I code, it
should have a 59 modifier attached
• An examination of the artery adjacent to the arterial
anastomosis is included in the 36147 code
• This should be interpreted as being within approximately 2 cm
of the anastomosis
• Use of the 75710 code would be warranted only if a larger
segment of the artery is examined
– In this situation examination of the feeding artery up to the aortic
arch and the artery perfusing the hand is generally medically
indicated
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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 patient’s
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 RS&I 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 RS&I Codes Together
• When a diagnostic RS&I code is used in association with a
therapeutic RS&I code, a 59 modifier should be attached
to the former
• In the instance described here – there are 2 diagnostic
RS&I codes and 1 therapeutic RS&I code
• The embolization coil placement is a therapeutic RS&I
• The post-coil angiogram via catheter RS&I is diagnostic
• The initial arteriogram RS&I described earlier is also diagnostic
• The diagnostic codes should have a 59 modifier attached
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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.
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