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This blog is a networking resource for ASDIN members. It is not intended to be utilized as legal or medical advice. ASDIN offers this blog as is, without any express or implied warranties, or other assurances as to the content of the material contained herein. ASDIN assumes no responsibility for errors or omissions contained herein, or for any actions taken or damages suffered by any person on the basis of, or in reliance upon, any of the information contained herein. Cases and images should ALWAYS be stripped of any/all patient-specific information (name, DOB, MR#, etc.). Cases should be well thought out and suitable for distribution. Language usage should be polite, collegial, and professional. If it is found that a participant is not using appropriate language, that participant’s comment may be blocked.


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Top tags: Policy and Procedure  tunneled dialysis catheter  central vein stenosis  Coding  articles of interest  Central Stents  policies  svc thrombus  accessory veins  accessory veins/ Coils  articles of interest; RESCUE  ASC  AVF  AVF endovascular at SSM STL  billing  case  Clot at tip of hemodialysis catheter  codes  Consents  Conversion  Declot  dialysis staff  DIALYSIS TECHNICIAN INTERVENTIONAL SCRUB ASSISTANT  Emergency  Great Stuff !!!!  Hemodialysis Cather  HeRO  IN jobs  MIPS QUALITY MEASURE 

Coding/Billing Question

Posted By Nephrology Associates PA Vascular Access Center, Tuesday, September 10, 2019

We received this email from our Billing Coordinator today:


"We are still not getting paid when we bill the 36595 with modifier 52.  I called Medicare again today to clarify and the code is being bundled with the  36581.  The only way to un-bundle this would be with a modifier.  I am not sure if there is an appropriate modifier to use in these cases as the 36595 is being done at the same site as the 36581.  Any guidance you could give me on this would be appreciated.  Thank you!"


I offered to share it here to see if anyone has had any luck getting this code paid, what modifiers they are using, etc.  We do use the coding manual tip of adding an additional statement to our procedure note.


Any info would be appreciated, thanks!

Tags:  billing  codes  reimbursements 

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August 2019 Articles of Interest

Posted By Abigail Falk, Monday, August 5, 2019
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President Trump's Speech encouraging in-home Dialysis and Transplantation

Posted By Eric Ladenheim, Friday, July 12, 2019

President Trump’s overall strategy of addressing the ballooning of expenditures for End Stage Renal Disease (ESRD) care by encouraging less expensive home dialysis and transplantation is brilliant but the devil is in the details. The tactics the Administration proposes to use are unnecessarily complicated and resemble a communist Chinese large scale transformative policy experiment rather than a democratic American legislative initiative.


At 4:45PM EST today on 7/11/2019 the detailed proposal was released for public inspection at The proposed rules are 413 pages. Ironically, the authority for the regulation comes from the Obamacare Law that the Administration supports eliminating.


Here is the experiment being proposed: The USA will be divided into 306 groups of zip codes called Hospital Referral Regions.  153 Hospital Referral Regions will be randomized to provide incentives for nephrologists to refer for home dialysis (mainly peritoneal dialysis) and transplantation and 153 regions will be randomized to the status quo.  The providers whose payments will be affected by the randomization will be the dialysis unit and the nephrologist.  Since this is a legislative experiment rather than a clinical trial the requirement for informed consent will be waived; rather, participation will be mandatory for the providers. It is called the ESRD Treatment Choices Model (ETC Model).


When the study is concluded in 2026, the data can be analyzed to determine whether the clinical and financial outcomes are better with the payment incentives and whether the administration’s goal of increasing home dialysis and transplantation through the incentive program is being achieved. Then the incentives could be implemented systemwide.


As we well know, in recent years, CMS has been trying to reduce ESRD expenditures by reducing the payment rates for the services are were needed to maintain hemodialysis access and has run into increasingly loud resistance from providers (like myself)  that performed those services and who had an opposing concentrated interest. This policy does an end-run around the HD maintenance payment conflict by incentivizing home dialysis (mainly peritoneal dialysis) and transplantation which all virtually all specialists agree is much cheaper to maintain. 


That home dialysis and transplantation are less costly than in-center hemodialysis there is no doubt. Whether the clinical outcomes of home dialysis are better than the clinical outcomes of in-center dialysis are presently uncertain. In my opinion the data currently available suggests clinical outcomes are about the same.  CMS proposes to resolve this uncertainty by structuring the payment reform measures as a massive nationwide prospective randomized non-blinded study that will study the effect of home dialysis/transplant payment incentives on cost and outcomes.


It is obvious that the costs of ESRD care have grown so high that something must be done or the Medicare system will be bankrupted.  But America doesn’t need a grand social experiment to decide whether to  incentivize less costly home dialysis and transplantation.  The administration has the legal authority under the Obamacare Act to implement the proposed innovation systemwide without limiting them to  randomly chosen geographic areas.  I would urge that the regulations be revised before the final rule is issued making the incentives applicable throughout the America, while it monitors clinical and financial outcomes.  Ultimately, the Secretary of HHS has the authority to stop the study  program as soon as it is clear that money is being saved without adversely affecting clinical outcomes and make the changes permanent. I hope this is done as soon as possible.




Eric Ladenheim MD

LDAC Vascular Centers


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Patient with acute thrombosis in radiocephalic fistula

Posted By Sun Ryoung Choi, Friday, June 28, 2019

A patient on hemodialysis three times a week visited the emergency room

The patient complained of dyspnea and chest x-ray showed cardiomegaly.

Vascular ultrasound was performed on suspicion of vascular access thrombosis.

Radiocephalic fistula had no thrill.

The attached image is an ultrasound examination performed at admission.

The ultrasound waveform is thought to be somewhat different from that of general thrombosis.

In conclusion, the patient underwent pericardiocentesis as an emergency after diagnosis with

acute cardiac tamponade.

I wonder if the shape of the ultrasonic waveform of the attached file is related to the cardiac


Thank you.



 Attached Thumbnails:

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Trerotola Device Issues

Posted By Terry Litchfield, Friday, April 26, 2019

Is anyone having issues with the tip of the Trerotola thrombectomy device separating from the basket portion?  Over the last year, we have seen several of these occur and note the MAUDE database is reporting many of them.  The tip is often not able to be retrieved.

The manufacturing changed to Mexico and there appears to be something happening.

And of course would want to make sure that anyone seeing a product defect should report the device failure to the manufacturer.  And please report additional catheters that have the same problem.  

Would love to hear if others are seeing this.

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March 2019 Articles of Interest

Posted By Abigail Falk, Monday, March 25, 2019
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Hand-held US devices

Posted By Ryan D. Evans, Thursday, March 21, 2019

Just a general technology question for the forum.  I am ordering new ultrasound equipment for our surgery center.  There have been recent advances allowing for hand-held US technology, such as the Sonosite iVis, Android, and Ipad devices.  However, I don't see any handheld US equipment which can measure fistula flow / pulse wave doppler.  I evaluate new fistulae by US to access maturation and measure flows.

Does anyone know if there are any hand-held US devices which can measure flow?  Thanks.

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Posted By Gregg M. Gaylord, Saturday, February 23, 2019

Has anyone hired a dialysis technician as a scrub tech for their Interventional cases?  If not, what were the barriers?  If so, any comments regarding state certification/scope of practice laws, training, or other caveats?


Thank You


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Clot at tip of Hemo catheter

Posted By Ramesh Soundararajan, Wednesday, January 23, 2019

Wanted to pick your brain about a patient. Patient has  hemodialysis catheter and an incidental echo and a transesophageal echo cardio gram picked up a 2 cm clot at the tip of the catheter. Blood cultures are negative but infectious diseases wants to remove the catheter. It’s working fine. Concerns about removing the catheter includes dislodgment of the 2 cm clot into the lungs. One thought is to infuse TPA to try to make the clot smaller another thought is a rather drastic step to perform open heart surgery to remove the clot. It’s possible that we have inadvertently removed such catheters  and patients have done fine but having known about this problem how would you approach it. Is there any literature to support any particular action

Tags:  Clot at tip of hemodialysis catheter  Hemodialysis Cather 

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Sign-up to be a reviewer of the new KDOQI VA Guidelines

Posted By Deborah J. Brouwer-Maier, Friday, January 18, 2019

Link to the National Kidney Foundation website- go to the Guidelines tab and then at the bottom of the page you can register to be a reviewer when the public review is active!  Please sign-up as these guidelines will impact your local Process of Care!!!

Tags:  New KDOQI Guideline Review 

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ultrasound in the dialysis unit for cannualiton

Posted By Deborah J. Brouwer-Maier, Thursday, December 13, 2018

Ultrasound guided cannulation is slowly becoming the standard of care outside the US.  See the 2017 guidelines on the use from Canada.  As IN’s you routinely use ultrasound imaging.  Many of you may even provide cannulation maps of a patient’s access to the dialysis unit.   The Associates program at the Feb meeting will be reviewing cannulation techniques and the issue of ultrasound imaging.  Wanted to get feedback on the interest in ultrasound guided cannulation or at least visualization before cannulation by your dialysis staff.  Do you support the idea?  Would an easy to use non-diagnostic imaging be of value to your clinics?  What about cost of the device?  The major adoption hurdle of training has already been disproven by Dr. Agarwal's study utilizing an easy to use simple point and see device.   

thanks Debbie

Download File (PDF)

Tags:  dialysis staff  ultrsound guided cannualtion 

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November 2018 Articles

Posted By Abigail Falk, Monday, December 3, 2018
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Pain in Arm with Clotted Fistula/CVC

Posted By Deborah J. Brouwer-Maier, Monday, November 5, 2018

Again, ASDIN has an opportunity to lead the way in vascular access.  Please help our colleague with her inquiry below.


A social worker posted on the CNSW listserv that her patient had a clotted access that has caused a lot of pain over the last few years, so we are cross-posting here. Patient now has a CVC and is getting a fistula in her other arm. The patient has swelling and pain in the arm where the fistula is clotted and has told the Social Worker that when the CVC is used it feels like her veins are being pulled out. Her surgeon has told her there isn’t a surgical option to resolve the pain she is feeling. Hate to hear of a patient having pain during each dialysis treatment.   Asking for ideas to see if you have tips or suggestions.


Tags:  Pain 

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Responsible Person Policy Question

Posted By Lindsay Fox, Tuesday, October 30, 2018

Please share any feedback to the following information request from an ASDIN member:


They would like to know what policies other centers have in place in regards to a responsible person staying in the waiting room for the duration of the patients procedure. We would like to implement this, but there are a few variables. Some patients do not have anyone and rely on share a fare or other transportation options, some have someone to drop them off, and return after procedure. 

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Endovascular AVF - WavelinQ

Posted By Alejandro C. Alvarez, Thursday, October 25, 2018

Dear Colleagues,


We had the Privilege to perform our first three endovascular AVF's using the wavelinQ system early this week.


All were an immediate technical success. We will follow the patients closely to the time of cannulation. 


I am very grateful to my team at the VAC and the patients that put their trust on us.


Here are the most meaningful images of our very first patient - these include a the final run and blood flow volume by me two days later


The second video is the final run of the second patient. 


The third is a still corresponding to the final patient.


Now we will follow them until the are ready to be accessed




Alejandro Alvarez


Download File (MOV)

 Attached Thumbnails:

 Attached Files: (1.66 MB)

Tags:  AVF endovascular at SSM STL 

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