CPT® Code 36908
Add-On Code

Official Description

Transcatheter placement of intravascular stent(s), central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and interpretation required to perform the stenting, and all angioplasty in the central dialysis segment (List separately in addition to code for primary procedure)

Common Language Description

The procedure described by CPT® Code 36908 involves the transcatheter placement of intravascular stent(s) specifically within the central dialysis segment. This procedure is essential for restoring adequate blood flow through narrowed or obstructed veins that are critical for hemodialysis, such as the axillary vein, subclavian vein, innominate vein, and vena cava. Patients suffering from hemodialysis-related central venous occlusive disease (CVOD) may experience symptoms such as elevated urea recirculation, increased venous dialysis pressure, and arm edema, which indicate compromised blood flow. The procedure begins with accessing the central venous dialysis segment through an arteriovenous (AV) graft or fistula, where a needle is used to puncture the graft. A guidewire is then threaded through the needle, and the needle is replaced with a vascular sheath to facilitate further access. Angiography is performed to visualize the central venous segments, allowing for the identification of any stenosis. If a narrowing is detected, transluminal balloon angioplasty is performed to dilate the affected area. Following this, if residual stenosis is present, a fine mesh or wire stent is deployed to maintain vessel patency. The entire process includes all necessary imaging and radiological supervision, ensuring that the procedure is conducted safely and effectively. The stent placement is a critical intervention that not only alleviates symptoms but also enhances the overall efficacy of the dialysis treatment.

1. Indications

The transcatheter placement of intravascular stent(s) in the central dialysis segment is indicated for patients experiencing symptoms related to hemodialysis-related central venous occlusive disease (CVOD). The specific indications include:

Elevated Urea Recirculation This condition indicates that the blood is not being adequately filtered during dialysis, leading to increased levels of urea in the bloodstream.
Elevated Venous Dialysis Pressure High venous pressure during dialysis can signify obstruction in the central venous segment, which may hinder effective blood flow.
Arm Edema Swelling in the arm can occur due to poor venous return, often a result of stenosis in the central veins used for dialysis access.

2. Procedure

The procedure for the transcatheter placement of intravascular stent(s) involves several critical steps to ensure successful intervention:

Accessing the AV Graft/Fistula The procedure begins with the puncture of the AV graft or fistula using a needle. This access point is crucial for introducing the necessary instruments into the vascular system.
Guidewire Insertion A guidewire is threaded through the needle into the vascular system, providing a pathway for subsequent devices. This step is essential for maintaining access to the central venous segment.
Vascular Sheath Placement The needle is exchanged for a vascular sheath, which allows for the introduction of larger instruments and facilitates the angiography process.
Angiography A catheter is placed over the guidewire, and angiography is performed to visualize the central venous segments. This imaging step is critical for identifying any areas of stenosis that require intervention.
Balloon Angioplasty If stenosis is identified, a balloon-tipped catheter is inserted over the guidewire and positioned at the site of narrowing. The balloon is inflated with dilute radiopaque contrast, which is visualized using fluoroscopy to ensure proper placement and effectiveness.
Balloon Deflation and Catheter Removal After the prescribed inflation time, the balloon is deflated, and the catheter is removed, allowing for assessment of the treated area.
Repeat Angiography A vascular catheter with a working channel is threaded over the guidewire, and angiography is repeated to evaluate for any resistant or residual stenosis that may still be present.
Stent Delivery If residual stenosis is detected, a fine mesh or wire stent is delivered to the area of stenosis through the working channel of the vascular catheter. The stent is deployed to expand and apply pressure against the vessel walls, ensuring that the blood vessel remains open.
Final Steps After stent placement, the catheter is removed, and a purse string suture may be placed to control any bleeding before the vascular sheath is finally removed. This step is important for minimizing complications and ensuring patient safety.

3. Post-Procedure

Post-procedure care following the transcatheter placement of intravascular stent(s) includes monitoring for any complications such as bleeding or infection at the access site. Patients may also be observed for signs of improved blood flow and resolution of symptoms related to CVOD. Follow-up imaging may be necessary to ensure the stent remains patent and that there are no further obstructions in the central venous segment. Additionally, healthcare providers will assess the patient's overall response to the procedure and make any necessary adjustments to their dialysis regimen to optimize treatment outcomes.

Short Descr	STENT PLMT CTR DIALYSIS SEG
Medium Descr	STENT PLMT CENTRAL DIAYLSIS SEG PFRMD DIAL CIR
Long Descr	Transcatheter placement of intravascular stent(s), central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and interpretation required to perform the stenting, and all angioplasty in the central dialysis segment (List separately in addition to code for primary procedure)
Status Code	Active Code
Global Days	ZZZ - Code Related to Another Service
PC/TC Indicator (26, TC)	0 - Physician Service Code
Multiple Procedures (51)	0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50)	0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62)	0 - Co-surgeons not permitted for this procedure.
Team Surgery (66)	0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Items and Services Packaged into APC Rates
ASC Payment Indicator	Packaged service/item; no separate payment made.
Type of Service (TOS)	2 - Surgery
Berenson-Eggers TOS (BETOS)	P2D - Major procedure, cardiovascualr-Coronary angioplasty (PTCA)
MUE	1

This is an add-on code that must be used in conjunction with one of these primary codes.

36818	MPFS Status: Active Code APC J1 ASC A2 Physician Quality Reporting CPT Assistant Article Illustration for Code Arteriovenous anastomosis, open; by upper arm cephalic vein transposition
36819	MPFS Status: Active Code APC J1 ASC A2 Physician Quality Reporting CPT Assistant Article Illustration for Code Arteriovenous anastomosis, open; by upper arm basilic vein transposition
36820	MPFS Status: Active Code APC J1 ASC A2 Physician Quality Reporting CPT Assistant Article Illustration for Code Arteriovenous anastomosis, open; by forearm vein transposition
36821	MPFS Status: Active Code APC J1 ASC A2 Physician Quality Reporting CPT Assistant Article Arteriovenous anastomosis, open; direct, any site (eg, Cimino type) (separate procedure)
36823	MPFS Status: Active Code APC C CPT Assistant Article Illustration for Code 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 and venotomy sites
36825	MPFS Status: Active Code APC J1 ASC A2 Physician Quality Reporting CPT Assistant Article Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); autogenous graft
36830	MPFS Status: Active Code APC J1 ASC A2 Physician Quality Reporting CPT Assistant Article Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); nonautogenous graft (eg, biological collagen, thermoplastic graft)
36831	MPFS Status: Active Code APC J1 ASC A2 CPT Assistant Article Illustration for Code Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous dialysis graft (separate procedure)
36832	MPFS Status: Active Code APC J1 ASC A2 CPT Assistant Article Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure)
36833	MPFS Status: Active Code APC J1 ASC A2 CPT Assistant Article Revision, open, arteriovenous fistula; with thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure)
36901	MPFS Status: Active Code APC J1 ASC P3 Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report;
36902	MPFS Status: Active Code APC J1 ASC G2 Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report; with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty
36903	MPFS Status: Active Code APC J1 ASC J8 Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report; with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis segment
36904	MPFS Status: Active Code APC J1 ASC J8 Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s);
36905	MPFS Status: Active Code APC J1 ASC J8 Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s); with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty
36906	MPFS Status: Active Code APC J1 ASC J8 Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s); with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis circuit
37252	Addon Code MPFS Status: Active Code APC N ASC N1 Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; initial noncoronary vessel (List separately in addition to code for primary procedure)
37253	Addon Code MPFS Status: Active Code APC N ASC N1 Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure)

LT	Left side (used to identify procedures performed on the left side of the body)
59	Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
XS	Separate structure, a service that is distinct because it was performed on a separate organ/structure
22	Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
51	Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
53	Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
58	Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
76	Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
77	Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
78	Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
79	Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
80	Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
AQ	Physician providing a service in an unlisted health professional shortage area (hpsa)
AS	Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CR	Catastrophe/disaster related
GC	This service has been performed in part by a resident under the direction of a teaching physician
GV	Attending physician not employed or paid under arrangement by the patient's hospice provider
GW	Service not related to the hospice patient's terminal condition
Q6	Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
RT	Right side (used to identify procedures performed on the right side of the body)
X4	Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
X5	Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician
XU	Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service