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Ashley Posted Tue 07th of February, 2017 10:32:18 AM
• Christine Posted 2 month(s) ago . Here is the typical scenario in our centers. The patient comes in with a thrombosed access. We evaluate the patient and determined that they may be a candidate for lysis so we inject Cathflow (tpa) into the access in the pre-procedural area. We then wait for 45 minutes to an hour and if the ACCESS has no flow we will transfer them to the procedure room and perform a standard percutaneous mechanical thrombectomy. Even if it does have flow they will probably get a fistula gram for angioplasty. In this scenario, is tpa billable as a separate procedure? • SuperCoder Posted 1 month(s) ago Hi, thrombolytic infusions performed either before or after mechanical thrombectomy should be billed. Short-term infusions are not billed separately. For example, if a patient receives a short infusion of tPA while on the angiography table would be included in the mechanical thrombectomy code. Please refer to the following link for more clarity, scenarios, and their explanation. Hope this helps! Thank you. • Christine Posted 1 month(s) ago sorry for the late reply but one last question, if patient is in pre op area and infusion is done and not on the angiography table can we bill for the 37212 if we do the Mechanical thrombectomy on same day? • Christine Posted 1 month(s) ago the patient is in pre OP from 45mins to an hour once the tPA is injected. not sure if you needed that info as well. thanks patient waiting to here back as the doctor is wanted to know if he should be billing this. • SuperCoder Posted 1 month(s) ago Hi, as you mentioned in your previous post, "We then wait for 45 minutes to an hour and if the ACCESS has no flow we will transfer them to the procedure room and perform a standard percutaneous mechanical thrombectomy". So in this case, it seems that thrombolytic infusion was performed to see whether the thrombus gets dissolved without having MT. Hence tpa should be billed here. Thank you. • Christine Posted 15 day(s) ago Right I agree but I was asking if billing the 37212 appropriate. thanks • SuperCoder Posted 14 day(s) ago Hi Please share some information of the procedure for us to be sure if 37212 would be appropriate in that particular case. Request you to create a new thread for this query. Thank you. Ok so I will attach notes for case: Technique: Timeout procedure was performed. The patient's hemodialysis access was prepped and draped in sterile fashion. The access was punctured in retrograde direction using micropuncture technique and local anesthesia and a 4 French catheter was advanced into the fistula toward the arterial anastomosis. 2 mg of t-PA mixed with 2 cc of saline and 2000 units of heparin were injected into the access as the catheter was withdrawn towards the puncture site. The catheter was then advanced again into the fistula and was fixed in place. After 30 min. of lysis, the access was reexamined. There still was no significant pulse in the access. The patient was then prepared for fistulogram and intervention. A contrast study of the fistula was obtained. This demonstrates that there is minimal antegrade flow in the fistula with residual thrombus within the access and therefore the patient was prepped for percutaneous mechanical thrombectomy. Summary: Partial thrombolysis of thrombus within the graft with reestablishment of flowTechnique ContinuedInstructions to Center: Above is the infusion therapy. Next procedure done is document below Hemodialysis access angiogram. Percutaneous mechanical AV graft thrombectomy. Axillary vein angioplasty and stent placement The procedure was performed under fluoroscopic guidance. The thrombosed hemodialysis access was prepped and draped in sterile fashion. The access was punctured in the direction of flow using micro-puncture technique and ultrasound guidance. A 7 French sheath was advanced into the access. The catheter placed in the venous and of the cannulation zone for thrombolysis was also exchanged for a 7 French sheath. Contrast was injected into the sheath. This demonstrates thrombosis of the hemodialysis access. Percutaneous Mechanical Thrombectomy: A Treratola Thrombectomy Device was inserted through the arterial side sheath and used to macerate thrombus within the venous side of the access. This thrombus was then aspirated through the sheaths. A 5 French catheter was then advanced into the access from the venous side sheath and passed across the arterial anastomosis into the axillary artery. Contrast was then injected, documenting normal arterial flow in the axillary artery without intraluminal thrombus within the arterial system. The brachial artery was patent and the radial and ulnar arteries in the forearm are patent. The thrombectomy device was then advanced through the catheter and employed within the brachial artery. The device was then was pulled back into the access, dislodging the arterial plug. Thrombus within the arterial side of the access was then macerated and aspirated through the sheaths. These maneuvers reestablished flow within the hemodialysis access. Arteriovenous fistulogram: A contrast study of the access was then obtained. This demonstrates a patent axillary artery to axillary vein graft. The arterial anastomosis was widely patent. No other significant narrowing was seen within the cannulation zone. There was recurrent moderate to severe stenosis at the venous anastomosis, along the distal margin of the existing stent. There was also moderate narrowing within the stent. The axillary vein, the subclavian vein and brachiocephalic vein are otherwise widely patent. The SVC was patent. Axillary vein angioplasty and stent placement: An 8 mm x 4 cm Bard Vaccess balloon was advanced across the venous stenosis. The balloon was inflated to its nominal diameter using a 3 mm syringe. The balloon was left inflated for 2 min. A completion angiogram following removal of the balloon demonstrated moderate residual stenosis at the dilatation site. A 10 mm x 4 cm Bard LifeStar stent was then advanced over the guidewire and positioned across the venous anastomosis, extending from the graft into the existing axillary vein stent. After the stent was deployed was dilated to 8 mm in diameter within the graft and 10 mm in diameter within the axillary vein. Completion angiogram revealed no residual stenosis. Closure Procedure The procedure was then terminated. 3-0 Ethilon slip knot sutures were placed at the sheath entry sites and the sheaths were removed. There were no complications. The sutures were removed prior to the patient's discharge in the recovery area. Summary: 1. Successful percutaneous mechanical hemodialysis access thrombectomy. 2. Venous stenosis at the venous anastomosis and axillary vein which was refractory to angioplasty and was treated with 10 mm x 4 cm stent placement placed coaxially within the existing axillary vein stent and here is what he wants to bill for all work done. 37212 THROMBOLYTIC VENOUS THERAPY T82.511A 37214 CESSJ THERAPY CATH REMOVAL T82.511A 36906 THRMBC/NFS DIALYSIS CIRCUIT T82.511A 36215 PLACE CATHETER IN ARTERY T82.511A 75710 ARTERY X-RAYS ARM/LEG T82.511A 76937 US GUIDE VASCULAR ACCESS T82.511A 76937 US GUIDE VASCULAR ACCESS T82.511A 99152 MOD SED SAME PHYS/QHP 5/>YRS T82.511A J2997 INJ ALTEPLASE RECOMBINANT 2 MG Let me know if the 37212 and the 37214 should or should not be billed thanks
SuperCoder Answered Wed 08th of February, 2017 05:53:52 AM

As per documentation, it will be appropriate to bill CPT 37212 for thrombolysis performed. Thank you.

Ashley Posted Thu 09th of February, 2017 10:15:03 AM
ok because on other thread you had said the way we use it "short term" we could NOT bill for it just want to make sure we can bill the 37212 with either of these codes 36904 or 36905.
Ashley Posted Thu 09th of February, 2017 10:20:08 AM
SuperCoder Posted 1 month(s) ago Hi, thrombolytic infusions performed either before or after mechanical thrombectomy should be billed. Short-term infusions are not billed separately. For example, if a patient receives a short infusion of tPA while on the angiography table would be included in the mechanical thrombectomy code. this is what I have as answer from before it is above for your reference the reason I am re address this as our doctors feel it is something we should be able to bill for and your answer is saying we can bill for the 37212 but did not address the 36906 that we billed as well. so this is getting confusing.
SuperCoder Answered Fri 10th of February, 2017 00:37:29 AM


Yes, as per CCI edits, code 37212 can be billed with either 36904 or 36905 using a modifier. Hope this helps. Thank you.

Ashley Posted Fri 10th of February, 2017 14:43:30 PM
Not really I do know the edits I am trying to get a definitive answer from the expert as before I was told by you we could not bill it with the case scenario I sent and now you are say yes and would just like answer with the case info provider that you requested to give a better answer because you were saying NO to short term use. hope that make sense.
Ashley Posted Mon 13th of February, 2017 15:35:11 PM
so can you give me a definitive answer that I can bill 37212 with 36905 with the above case notes?
SuperCoder Answered Mon 20th of February, 2017 09:31:53 AM

Hi Sorry for delay in response,

Here is our analysis. We are discussing thrombolysis of the dialysis circuit access within an hour of thrombectomy of the access.

The question is whether, for a thrombosed access, you may report thrombolysis code 37212 with a thrombectomy/thrombolysis code from 36904-36906.


Short answer: You can’t report 37212 for a dialysis catheter service.


Support: AMA's CPT® Assistant, Feb. 2013, includes an article called "Transcatheter Cardiovascular Procedures" about 37211-37214 and similar codes.


In the article, the AMA states 37211-37214 "are not used for thrombectomy/thrombolysis of the dialysis AV shunt, in which code 36870, Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical thrombus extraction and intra-graft thrombolysis), would be reported."

CPT® 2017 deleted 36870, and the replacement codes are 36904-36906. But the point is that the AMA has indicated initial-day code 37212 is not used for thrombolysis of the dialysis AV shunt.


Longer answer: The descriptors for 36904-36906 all start with this wording: "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) ..." So the codes cover thrombolysis, thrombectomy, or both (along with all the other listed services).

According to a consultant in attendance at the AMA CPT® 2017 symposium, discussion of these new dialysis codes emphasized that the intent was to create comprehensive codes, meaning that you choose the most extensive procedure performed, code that, and include pretty much everything else in that code (keeping in mind exceptions supported by code descriptors and guidelines).


Even if a practice wanted to argue that the thrombolysis and thrombectomy occur at separate sessions and should be coded separately, each code in 36904-36906 has a DOS MUE of 1 with MAI 3. Because of that MUE and MAI, to get both paid you would have to appeal and convince the payer each service deserves to be paid separately (which may be tough given that thrombolysis is done in the pre-procedural area for less than an hour and then the patient immediately goes to the procedure room – a payer may want to see a more significant difference in time to count these services as separate).

Ashley Posted Tue 21st of February, 2017 10:49:24 AM
thanks so much :)
Ashley Posted Tue 21st of February, 2017 11:58:50 AM
Can we bill for the tPA used since it was not part of the procedure? J2997
SuperCoder Answered Mon 27th of February, 2017 02:39:17 AM


Based on general rules, the entity bearing the cost of the tPA should report it. So in a facility setting, the facility would report it, and in an office setting, the physician reports it. It's possible the claim will run into coverage rules if the payer has a policy limiting J2997 coverage to specific diagnoses or CPT/HCPCS pairings.

It's worth noting that in the MPFS 2017 Final Rule Direct PE Inputs folder, the Supply file shows heparin factored into the cost of 36904-36905. tPA is not listed as a supply factored into the PE RVUs for those codes.

The Direct PE Inputs download is available here:



Ashley Posted Mon 27th of February, 2017 11:40:41 AM
Perfect thanks so much
SuperCoder Answered Mon 27th of February, 2017 22:52:01 PM

You are welcome.

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