37191

Insertion of Intravascular Vena Cava Filter

CPT code 37191 describes the endovascular insertion of an intravascular vena cava filter. This procedure is a critical intervention used to prevent pulmonary embolism (PE) in patients who have been diagnosed with deep vein thrombosis (DVT) or are at extremely high risk for it, but for whom standard anticoagulation therapy is either contraindicated, has failed, or has resulted in complications. The procedure is typically performed in an interventional radiology suite or a cardiac catheterization laboratory. It begins with the clinician obtaining percutaneous vascular access, most commonly through the right internal jugular vein or the common femoral vein, using the Seldinger technique. Under fluoroscopic guidance, a catheter is advanced into the inferior vena cava (IVC). A diagnostic cavogram is then performed to visualize the anatomy, identify the locations of the renal veins, and measure the diameter of the IVC to ensure proper filter sizing and placement. Once the target site is identified—usually just inferior to the renal vein orfices—the filter delivery system is advanced. The filter, which is a small, umbrella-like device made of metal (such as nitinol or stainless steel), is then deployed. Post-deployment imaging is conducted to confirm the filter is expanded correctly and positioned stably. This code is a 'bundled' code, meaning it includes all components of the service: the initial vascular access, all vessel selections required to reach the IVC, and all radiological supervision and interpretation (RS&I), including ultrasound guidance for the initial puncture and the fluoroscopic roadmapping used during the procedure. It encompasses both permanent and retrievable filter types.

Clinical Indications

  • Acute proximal deep vein thrombosis (DVT) in patients with a contraindication to anticoagulation therapy.
  • Recurrent pulmonary embolism (PE) despite adequate therapeutic anticoagulation.
  • Complications arising from anticoagulation therapy (e.g., severe gastrointestinal hemorrhage).
  • Failure of anticoagulation (e.g., progression of DVT or PE during therapy).
  • Large, free-floating iliofemoral or caval thrombus.
  • Prophylactic placement in extremely high-risk trauma patients with multiple fractures or spinal cord injuries.
  • Patients with poor cardiopulmonary reserve where a small PE could be fatal.

Procedure Steps

  1. Position the patient in a supine position and prepare the access site (jugular or femoral) using sterile technique.
  2. Administer local anesthesia at the puncture site.
  3. Perform percutaneous venous puncture using ultrasound guidance.
  4. Insert a guidewire and sheath into the venous system.
  5. Advance a pigtail or diagnostic catheter into the inferior vena cava.
  6. Perform a venogram (cavogram) using contrast injection to map the IVC, identify renal veins, and measure the caval diameter.
  7. Exchange the diagnostic catheter for the filter delivery sheath over a stiff guidewire.
  8. Position the delivery sheath at the desired infrarenal level.
  9. Deploy the vena cava filter by retracting the sheath or advancing the pusher mechanism.
  10. Perform a final fluoroscopic check to ensure the filter is correctly oriented and fixed against the vessel walls.
  11. Remove the delivery system and apply manual compression to the access site for hemostasis.

Coding Guidelines

  • 37191 is a comprehensive code that includes vascular access, catheterization, and all imaging guidance (ultrasound and fluoroscopy).
  • Do not report 76937 (ultrasound guidance for vascular access) in conjunction with 37191.
  • Do not report 75825 (venography, caval, inferior, with RS&I) separately as it is considered part of the intraprocedural roadmapping.
  • If the physician attempts to place a filter but the procedure is unsuccessful or abandoned after the cavogram, report 75825 instead of 37191.
  • For the repositioning of an existing vena cava filter, use code 37192.
  • For the retrieval/removal of a retrievable vena cava filter, use code 37193.
  • Only one unit of 37191 should be reported per session, regardless of the number of filters placed (though multiple filters are rare).

Associated ICD-10 Codes