37192

Repositioning of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed

The clinical description of CPT code 37192 outlines the intricate steps and technical requirements involved in the repositioning of an intravascular vena cava filter via an endovascular approach. An inferior vena cava (IVC) filter or, less commonly, a superior vena cava (SVC) filter is typically inserted to prevent life-threatening pulmonary embolisms in patients who have venous thromboembolism but contraindications to anticoagulation therapy. Over time, or immediately after placement, a filter may migrate, tilt, or be positioned suboptimally, increasing the risk of thrombosis, vessel perforation, or diminished efficacy. To mitigate these risks, the physician performs a repositioning procedure. The patient is prepared and draped in a sterile fashion. Local anesthesia is administered at the access site, typically the common femoral vein or internal jugular vein. The physician utilizes ultrasound guidance to gain percutaneous access to the selected vein and places a vascular sheath. Under continuous fluoroscopic guidance, a specialized snare or retrieval catheter system is advanced over a guidewire through the venous system until it reaches the filter. The physician performs a venogram to visualize the filter's current position, assess its relationship to the renal veins, and check for any trapped thrombus. If significant thrombus is present, repositioning may be contraindicated. Once deemed safe, the physician uses the snare to engage the apical hook of the filter. The filter is then partially collapsed into the retrieval sheath, disengaging its struts from the caval wall. The entire system is then carefully manipulated to the new, desired location within the vena cava, typically infrarenal for an IVC filter. A repeat venogram ensures the target landing zone is appropriate. The filter is then redeployed in the corrected position. Final venography is performed to confirm the optimal placement of the filter, its proper expansion, and the absence of caval injury. The delivery system and sheath are subsequently removed, and hemostasis is achieved at the puncture site via manual compression. CPT code 37192 is comprehensive, encompassing the vascular access, selective catheterization, intraprocedural roadmapping, and all associated radiological supervision and interpretation, including both ultrasound and fluoroscopic imaging guidance when performed. This code reflects a distinct procedural service separate from the initial insertion or complete removal of a filter, focusing solely on correcting the position of an existing filter within the vascular system.

Clinical Indications

  • Filter migration from the original deployment site.
  • Filter tilt greater than 15 degrees reducing efficacy.
  • Suboptimal initial placement (e.g., deployed too high above the renal veins).
  • Impending penetration or perforation of the caval wall by filter struts.
  • Need to adjust filter position to accommodate a new anatomical issue or surgical intervention.

Procedure Steps

  1. Patient positioning, sterile prep, and administration of local anesthesia.
  2. Percutaneous venous access (e.g., femoral or jugular) typically utilizing ultrasound guidance.
  3. Insertion of a vascular sheath and advancement of a guidewire.
  4. Advancement of a retrieval or snare catheter over the guidewire to the vena cava filter site under fluoroscopic guidance.
  5. Performance of a cavagram (venogram) to assess filter position, orientation, and exclude massive trapped thrombus.
  6. Engagement of the filter hook using an endovascular snare device.
  7. Sheathing of the filter to collapse the struts and detach them from the caval wall.
  8. Relocation of the filter to the targeted optimal location within the vena cava.
  9. Redeployment of the filter in the new position.
  10. Final cavagram to confirm correct placement, filter integrity, and absence of caval injury, followed by catheter removal and hemostasis.

Coding Guidelines

  • Do not report 37192 in conjunction with 37191 (Insertion of intravascular vena cava filter) or 37193 (Retrieval of intravascular vena cava filter) for the same filter during the same session.
  • Code 37192 includes all associated radiological supervision and interpretation, ultrasound guidance for vascular access, and intraprocedural fluoroscopy.
  • Do not report 76937 or 77001 separately for imaging guidance associated with this procedure.
  • If diagnostic venography is performed prior to the decision to reposition, and constitutes a fully diagnostic study not previously done, it may be reported separately with modifier 59 or XU, but roadmapping is included in the base code.
  • This code applies to both inferior vena cava (IVC) and superior vena cava (SVC) filters.

Associated ICD-10 Codes