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Outcomes comparison of HeRO and lower extremity arteriovenous grafts in patients with long-standing renal failure

      The Hemodialysis Reliable Outflow (HeRO) catheter-placement procedure typically involves implantation of a prosthetic graft in the upper extremity that is sutured to the brachial artery. It is then tunneled in the subcutaneous plane to the deltopectoral groove, where it is connected to a central venous catheter placed by the Seldinger technique. The entire device remains internal in an effort to reduce the infection rate. There is currently no single Category I CPT code that fully describes this service.
      The open surgical portion of HeRO catheter placement appears identical to one aspect of CPT code 36830 (Creation of arteriovenous fistula by other than direct arteriovenous anastomosis [separate procedure]; nonautogenous graft [eg, biological collagen, thermoplastic graft]), while the catheter placement portion of HeRO placement, if performed alone, would be reported with CPT code 36558 (Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older).
      In terms of physician work, the open surgical aspects of HeRO system placement are equivalent to the arterial dissection and arterial anastomosis portions of CPT code 36830. Since CPT code 36830 also includes the venous outflow dissection and a sutured venous anastomosis, it would be inappropriate to report a full CPT code 36830 for implantation of this device. Therefore, the Society for Vascular Surgery (SVS) recommendation has been to append the -52 limited service modifier, serving to identify that less than the full work of 36830 is being performed. The latter half of the procedure involves central venous catheter placement to facilitate venous return. The SVS believes that there is work equivalence between the catheter portion of HeRO system placement and CPT code 36558.
      Until a Category I CPT code is created, the SVS recommends an interim coding strategy for placement of this FDA-510k-approved hemodialysis system through a combination of Category I CPT codes:
      • CPT code 36830 -52 to represent the open surgical portion of this procedure;
      • CPT code 36558 (-51) to represent the tunneled catheter portion of this procedure (and subject to the multiple procedure payment reduction);
      • If ultrasound guidance is required for the tunneled catheter portion of the procedure, CPT code 76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting [List separately in addition to code for primary procedure]) would be additionally reported assuming all CPT requirements are met, including image documentation;
      • If fluoroscopic guidance is required for the tunneled catheter portion of this procedure, CPT code 77001 (Fluoroscopic guidance for central venous access device placement, replacement [catheter only or complete], or removal [includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position] [List separately in addition to code for primary procedure]) would be additionally reported assuming all CPT requirements are met, including image documentation.

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