Does 36904 require prior authorization?

No, 36904 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 36904?

Medicare facility rate: $320.65. Non-facility rate: $1740.85. Work RVU: 7.31.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

7.31

Facility

$320.65

Non-Facility

$1740.85

When an ABN is issued and liability is being transferred, a signed ABN Form CMS-R-131 must be retained in the beneficiary record; Part A MAC claims require occurrence code 32 and the ABN date.
The medical record must include the ordering provider's assessment related to the patient's complaint for the visit and relevant medical history.
Results of pertinent tests or procedures must be documented; for diagnostic tests, report the test result if known or otherwise the symptoms prompting the test.
Office visit records and operative reports must be signed and dated; all services ordered or rendered to Medicare beneficiaries must be signed.

Claims for dialysis access maintenance billed to Medicare Part A or Part B should be submitted when coding conforms to the applicable Local Coverage Determination L34062 and applicable NCCI and OPPS coding/packaging edits.
For services that require a referring or ordering physician, claims must include the referring/ordering physician's name and NPI to be eligible for payment.
Percutaneous or open interventions to restore or maintain functional patency of an arteriovenous (AV) dialysis access (AV fistula or AV graft) for compromised flow, threatened occlusion, recent thrombosis, or structural abnormalities such as pseudoaneurysm.
Percutaneous evaluation and treatment for fistulae that are failing to mature as expected (non-maturing fistula).
Intervention is indicated for venous outflow impediment evidenced by elevated venous pressure in the AV dialysis access.
Intervention is indicated when static venous pressure ratio (venous/arterial) is above 40%.

A56460 — Billing and Coding: Dialysis Access Maintenance

L34062 — Dialysis Access Maintenance

CARELON-dialysis-access-evaluations-2024-11-01 — Dialysis Access Evaluations

AETNA-CPB-0568 — AngioJet Rheolytic Thrombectomy System

Ask Verity about documentation requirements, denial risks, or coverage in your state.