Ask Dr. Z

Revision and Stenting of Fistula/Same Zone

This patient had a brachiocephalic fistula. Excision of an aneurysm/aneurysmorrhaphy was performed on the "middle portion of the fistula". Stenting was performed for an 80% "outflow stenosis", specifically the axillary vein. The Dr. Z Vascular & Endovascular Surgery Coding Reference states that, if surgical revision is performed on a graft, we should not code angioplasty/stenting within the graft (anastomosis to anastomosis). How do we code when it's a fistula? In the case above, is it okay to code the stent as well as the revision, since the stenting was performed in the axillary vein and the revision was on the brachiocephalic fistula? Are we looking to see if different veins are worked on or for words like "outflow"? Or do you believe we should not code for both a revision and angioplasty/stenting for fistulae when done in the same zone?

Revision of brachiocephalic fistula with resection of venous stent

The patient underwent revision of brachiocephalic fistula of arterial inflow using PTFE graft from axillary to the cephalic vein fistula. In addition, the patient previously underwent angioplasty and stenting of the arterial inflow segment. The stent was removed at this operative session because it is situated medially at the arterial inflow site, and this is the planned distal anastomotic site for the revision. Is there a code for resection of the stent in the cephalic?

Creation of Brachiocephalic Fistula with Patch Repair due to No Pulse in Fistula

If a surgeon creates a fistula (32821) and there is no pulse, and he therefore does a revision and repairs it with a harvested vein and does vein patching, can you code the revision as well (36832), even though both codes are separate procedures?

Left Arteriovenous Fistulogram with Central Venous Angioplasty

Please help; I'm very confused. I would like to know what codes to use for a left AV fistulogram with central venous angioplasty and left brachiocephalic arteriovenous fistula, surgical revision with flow reducing tapered plication of the AV anastomosis. "Patient with left upper arm brachiocephalic arteriovenous fistula with excessive pressure due to presumed venous stenosis and additional excessive arterial inflow. 54-year-old gentleman with longstanding history of end-stage renal disease on hemodialysis. He dialyzes via a left upper arm brachiocephalic arteriovenous fistula. He has undergone previous repair of an apparent bleeding pseudoaneurysm at an outside facility, but continues to have problems with dramatically swollen left upper extremity and wound breakdown at the previous surgical site. He comes to the operating room at this time for further evaluation and treatment as able."

Revision or Partial Excision of AV Fistula

Patient has a functional LUE AV fistula and non-functional aneurysmal RUE AV fistula, causing pain - no infection. The physician decides to remove the RUE cephalic vein.

"We started with dissecting the cephalic vein down to the brachiocephalic anastomosis. The cephalic vein was noted to be extremely calcified and aneurysmal as it was transected close to the brachiocephalic anastomosis. An extensive endarterectomy had to be carried out including the brachial artery, requiring three sutures distally to tack down the distal endpoint. We were then able to close the cephalic vein close to the brachiocephalic anastomosis, closing the arterial venous anastomosis over the brachial artery. The suture line was in the cephalic vein, close to the brachiocephalic anastomosis, and endo venectomy had been carried out here too. We continued to excise the rest of the cephalic vein along the entire length of the arm, to the shoulder with, extensive mobilization."

Is this a revision 36832 or partial excision 37799? Is the brachial artery endarterectomy separately reportable?

Brachiocephalic AV Fistulogram with ligation of venous tributary

Does ligation of a flow-stealing venous tributary via cutdown count as 36909 or open revision 36832? "History: Non-maturing brachiocephalic AVF. Procedure: Angiography of right brachiocephalic fistula reveals 90% stenosis from proximal aspect of fistula, approximately 1 cm distal to the anastomosis. Lesion was ballooned with 4, 5, and 6 mm balloons. Completion angio reveals less than 10% residual stenosis (36902). There was also noted at this time a venous tributary in the mid upper arm that was stealing a significant portion of flow through the fistula. A small transverse mid upper arm incision is made, and the venous tributaries were identified and ligated. Completion angio reveals excellent improved flow with no residual stenosis at the proximal anastomosis and no further flow through the ligated tributary."

Brachiocephalic AV Fistula PTA via Native Radial Artery

How would you code a wrist radial artery access with catheter navigated into brachiocephalic AV fistula and PTA of fistula peripheral segment?

Revision of Fistula with Ligation of Tributary

Operative note states: "Fistulogram with angioplasty and revision of fistula with ligation of tributary. The patient has poorly functioning right radiocephalic fistula. Fistulogram was found to have stenosis just distal to the anastomosis up beyond a large tributary. This was angioplasited with 4 x 80 and 6 x 80 balloon, and large tribrutary was then ligated through separate incision. Wire was manipulated using a Bern catheter down into the radial artery. Angioplasty was performed of the stenotic area with good results. A large tributary was located and marked and the vein dissected free from surrounding tissue up to level of the fistula and ligated with 2-0 silk and divided." I am not sure if the ligation of tributary would be reported with code 37607, as it is not the fistula itself. Also, I do not believe this is a revision of the fistula. I am reading this as fistulogram (36147), angioplasty (35476, 75978), and the ligation. There really was no revision of the fistula. Your help is appreciated.

Revision of Collateral Vein, Angioplasty, and Stent

Can you tell me if this would be considered an open procedure and if you would only report code 36832? "DuraPrep and sterile draping of the left upper extremity in the routine manner. Using the SonoSite, the location of the collateral vein arising from the left brachiocephalic arteriovenous was identified. An axial incision was made over the fistula at this location. Sharp dissection down to the fistula and the collateral vein, which was controlled by circumferential dissection and secured with 0 silk ties. Access through this large collateral vein with a micropuncture kit into the left upper arm brachiocephalic arteriovenous fistula. Insertion of a 6 French sheath. Wire exchange, which was advanced across the stenosis. Viabahn stent graft was then deployed across the stenosis. Post deployment balloon angioplasty conquest balloon up to 18 atm with 0% residual stenosis. The large collateral vein was then triply ligated with 0 silk. Irrigation and hemostasis. Wound closure in layers dermal closure staples."

AVF Revision

I have my provider billing a revision (36832) for aneurysmal resection with ulcerations. He notes that there was no penetration into the fistula wall. Would this support a revision? My gut is telling me no, but I want to be certain. "Patient had 2 aneurysmal areas on the fistula with ulcerations on top of the aneurysm. At this point in time elliptical incision was made and surrounding the area of the aneurysms. The aneurysms are resected. There is no penetration into the AV fistula wall for which reason the wounds were both closed in a double layered fashion with absorbable suture."

36832

Greetings, A patient presents with compression of a fistula due to a hematoma. The physician evacuates the hematoma. Upon evacuation of the hematoma, pulsatile bleeding was still present originating from the back wall of the transposed brachiobasilic fistula present in the mid upper arm. I think this is coded as a revision of a fistula (36832) and not a revision of a fistula w/ thrombectomy (36833). I was wondering if repair of a blood vessel (35206) is better. What are your thoughts? Lesley

36147

Please do NOT include any actual patient medical records with your question. The patient is a 54-year-old woman with a history of end-stage renal disease who is status post creation of a left forearm arteriovenous fistula at an outside hospital. SURGICAL PROCEDURE IN DETAIL: the left upper extremity was prepped and draped in standard surgical fashion. A forearm arteriovenous fistula was present. This fistula was cannulated using a micropuncture set and a fistulogram was obtained. The study revealed an antecubital arteriovenous fistula with outflow to both the cephalic and basilic veins. The central veins were unremarkable. The decision was made to proceed with a left brachiocephalic arteriovenous fistula. Through a transverse incision above the elbow, the cephalic vein was circumferentially dissected and transposed onto the brachial artery. An end-to-side anastomosis was performed using a running 7-0 Prolene suture. The proximal anastomosis of the antecubital vein arteriovenous fistula was dissected through the same incision. This fistula was ligated and divided between clamps and oversewn with Prolene suture. My question is - is this a revision since patient has forearm fistula a new fistual from basillic to brachial, if it is new fistula how do we capture the fistulogram and ligation of old one? Thanks

Attempted AV Fistula Revision

Physician attempted AV fistula revision (36833). He was unable to complete due to significant stricture. He did perform several embolectomy catheter sweeps to remove significant thrombus. He then created a new AV fistula (36830). Can we bill for 36833 with a -53 modifier and 36830?

Brachiocephalic AVF

I have been using code 36821 for both radiocephalic and brachiocephalic fistulae. My physician states code 36821 is okay for radiocephalic but not for brachiocephalic, and he states code 36818 is for both cephalic transposition and brachiocephalic fistula. I'm very confused now. Please clarify.

Bypass to a Fistula

Left upper extremity bypass with reverse great saphenous vein from the radial artery to the proximal brachiocephalic arteriovenous fistula with ligation of arteriovenous fistula at the level of the arteriovenous anastomosis. What are all codes associated with this procedure?

Accessing brachial artery in brachiocephalic fistula

When the MD accesses the brachial artery in a brachiocephalic fistula, is this always reported with 36140-XS? Or is the perianastomosis brachial artery included in 3690X? Example: "Real-time ultrasound guidance was used to access the brachial artery in retrograde fashion. Fistulogram was performed. Based on the findings, angioplasty of the cephalic vein was performed."

Fistula Anastomosis

Is the fistula anastomosis considered an arterial anastomosis or a vein anastomosis? I have been coding a stenosis in the fistula anastomosis (like a brachiocephalic fistula) with codes 35475/75962.

Fistula Revision

Will code 36833 cover the following procedure? Or are codes 36147 and 36148 also needed? Please advise. "Patient with aneurysmal left brachiocephalic AV fistula with aneurysmal stick site, skin ulceration over upper stick zone. Micropuncture needle was inserted into proximal portion of fistula with wire advanced under fluoroscopy into upper fistula beyond aneurysmal stick zones. Sheath inserted up into subclavian vein and parked there with fistulogram done. Long segment of high grade stenosis (80%) began just beyond aneurysmal upper stick zone. Stenoses were balloon-dilated with good result and puncture site sutured. Attention turned to aneurysmal site in upper stick zone. Ulcer was excised with elliptical incision back to healthy skin on both sides, down to fistula. Inflow portion of fistula into stick zone was dissected and clamped. Patient was heparinized. Part of aneuyrsmal fistula was excised, revealing ulcer had penetrated into fistula with layer of thrombus between scabbed area and fistula. This was excised including excessive thrombus. Opening was oversewn in two layers, clamps were released, and suture line was hemostatic. Subcu and skin sutured."

37609

Hi Dr. Z, Here's the coding scenario: Doctor placed an AV fistula, however not maturing, brought patient back to ligate veins surrounding the fistula because blood was going to the veins instead of fistula. What CPT code can we use? 37609 is ligation of the av fistula but since he did not ligate the fistula, just the veins surrounding it. He was thinking of revision 36832, is this appropriate. Your input is appreciated. Thank you, Ginie

AV fistula resection or excision

My question is in regards to an AV fistula resection or excision .. The patient presented with a hemorrhage at the AV fistula access site. He was taken to the OR. The ulcer site was opened. The fistula was mobilized both proximally and distally to the site of the perforation. Clamps were applied proximally and distally. The doctor excised the ulcerated segment of the fistula, then mobilization of the arterial end allowed for an end-to-end anastomosis between the arterial end and the venous end of the fistula. Would this just be a revision of an AV fistula (36832) or is this more in depth? I am struggling with finding a code that fits this procedure.

Revision of AV fistula with a venovenostomy anastamosis

Would the correct code for this procedure be 36833 or unlisted CPT 37799 since we cannot find a CPT code for a venovenostomy anastomosis? "Procedure performed: Revision of left upper extremity cephalic AV fistula with translocated basilic vein AV fistula and a venovenostomy anastomosis. Operative technique: The distal aspect of the cephalic vein was ligated just below the area of occlusion and the vein divided. There was thrombus at this level, which was easily removed, and the remaining portion of the cephalic vein appeared to be patent. The basilic vein was ligated distally. The vein was then mobilized and tunneled to the open incision over the cephalic vein. An end-to-end anastomosis venovenostomy was performed using 6-0 Prolene sutures. Upon completing the anastomosis, flow was instituted through the vein and the AV fistula, and excellent thrill was palpable."

Fistulogram with right brachiocephalic vein angioplasty

Would I report 36901 and 36907 or 36902? "The right arm was prepped using ChloraPrep. Under ultrasound guidance, the right brachial basilic vein transposition fistula was accessed in antegrade fashion near the arterial anastomosis. A fistulogram was performed in stations to the chest. This demonstrated a recurrent, severe approximately 75% stenosis of the right brachiocephalic vein. Given the excellent palpable thrill of the fistula, assessment of the arterial anastomosis was deferred. Subsequently, the stenosis was angioplastied to 16 mm using a 16 mm x 4 cm Atlas Gold angioplasty balloon. Repeat fistulogram was performed. This demonstrated improvement in the brachiocephalic vein stenosis but with persistent moderate stenosis remaining. The stenosis was again angioplastied to 16 mm using the Atlas Gold balloon with prolonged angioplasty balloon inflation time utilized. Repeat fistulogram was performed, demonstrating mild less than 30% residual narrowing of the brachiocephalic vein."

Radial artery puncture attempted fistula access

"Patient has a brachiocephalic fistula. The left cephalic vein fistula was accessed antegrade. The sheath was used to inject contrast to perform fistulogram. Retrograde injection was performed with a balloon occlusion of the fistula, which revealed ~90% stenosis of the proximal fistula vein ~2 cm distally to the AV anastomosis. Left radial artery was then accessed at the wrist under local anesthesia and ultrasound guidance. Wire and catheter were unable to access the fistula from this location. Therefore retrograde fistula access in the proximal upper arm was obtained under ultrasound guidance and with local anesthesia. The stenosis was angioplastied with a balloon with good result." Can we code for the radial artery attempted access? Would 36140-59 be correct in addition to 36902?

Super fistulization of right brachiocephalic AV fistula

"History: Patient with a previously created RT brachiocephalic AV fistula with severe stenosis that required an interposition graft who now suffers from elevated pressures during dialysis. Pre-op fistulogram showed widely patent SVC, IJ, and cephalic veins, but high grade occluded subclavian vein with the inability to be recanalized endovascularly. Operation: Incisions made and RT cephalic and IJ veins identified and dissected. Subcutaneous tunnel was created between the cephalic and IJ veins that an 8 mm ringed PTFE was brought thru. Venotomies made in both the cephalic and IJ veins and end-to-side anastomosis were created. There was no palpable thrill in the bypass graft or in the IJ vein. Retrograde fistulogram showed stenosis of the AV fistula. 5 French sheath was placed in the AV fistula, and the stenosis was angioplastied with a balloon with brisk thrill throughout the AV fistula." Are codes 36832 and 36902 correct? Or should it be an unlisted CPT code? If unlisted, what CPT codes are comparable to this procedure?

27592 vs. 27596

We have a patient who had an above-knee amputation (27590) one month ago, but then came back due to infection and had a revision, although they are doing a guillotine type revision being left open at the end of the case. The patient went back to the operating room five days later and had another revision with more bone, but this time it was closed. Would we code both revisions as 27596-78, or the first revision as 27592 and second revision as 27596?

Second Stage Vein Transposition

It is my understanding that if, after the creation of an AV fistula, a vein transposition is performed at a later surgical session on the same fistula, that this should be reported with code 36832 (revision of AV fistula) instead of codes 36818-36820 for vein transpositions. My physicians disagree, stating that performing the vein transposition requires significantly more work than other, more simple revision procedures, and they believe the work RVU is more consistent with codes 36818-36820. They don't agree that the description in the CPT Codebook correlates to a one- or two-stage procedure and think they should use it in either scenario. I am hoping you can shed some more light from a clinical perspective that can assist me in explaining to them why this procedure should be coded this way.

AVF/AVG Declotting Procedures in Global Period

Many of our dialysis patients have angioplasties or thrombectomies or stents performed in AVF/AVG. These procedures fall in the global period of the same AVF/AVG placement or revision. What modifier should be used for the physician charges for the procedure performed in the global period? The fistula repair is usually related to the patient's underlying illness (renal disease) not directly related to the fistula's creation or revision and is not strictly a complication of the earlier procedure. 

Brachiocephalic fistula with basilic vein access

The patient had a brachiocephalic fistula for dialysis with stenosis in the distal subclavian vein. Two different access sites were used to treat the stenosis with angioplasty and stenting. One access site was in the femoral and the other in the basilic vein. The cephalic vein was also catheterized with imaging performed through the basilic access. I know the catheter placement from the femoral access site would be coded with 36012, but the basilic access is really throwing me off since it was not the outflow vein. What codes would you recommend for the rest of the procedure?

AV fistual revision

Q. My physician has "revision" of brachiocephalic fistula, but i think that this is a new creation. how would you code this? a incision was made over the course of the vein from the old scar just across the elbow. the vein was mobilized over about 4 to 5 cm. there was a large deep branch that was identified, ligated and divided. it was thought that the vein was small in that last 2cm segment and that it could be improved by making a new anastomosis to the brachial artery just above the elbow. the deep fascia was incised and the brachial artery was mobilized ovver about 2 cm. the vein was ligated and divided distally. the pt was given 3,000 units of heparin intravenously. the artery was clamped and opened obliquely. an end-to-side anastomosis was fashioned with running prolene. the clamps were released and there was an excellent thrill. the vein was somehat thick and it was thought large clips would be too big for the smaller size artery. the incision was closed.

AVF revision vs aneurysm repair

I am not sure if this would be an aneurysm repair (35011) or a revision (36832). What are your thoughts?

"The skin over the left arm distal to the aneurysmal portion was instilled with lidocaine. The skin was cut with a 15 blade and deepened with electrocautery. The fistula near the arterial anastomosis at the antecubital crease was controlled with clamp. The fistula near the arterial anastomosis was ligated with 5-0 Prolene in double layers. The aneurysmal portion of the fistula including the overlying skin was resected sharply with scissors. The vein in the proximal arm was also ligated with 5-0 Prolene suture in double layers. Hemostasis was achieved. The incision was closed in layers with 3-0 PDS sutures, and the skin was now closed with 4-0 Nylon sutures and staples. A sterile, occlusive dressing was placed."

peripheral and central circuit AV angioplasty?

"Open thrombectomy of AV fistula. Thrombus was extracted, but no good back bleeding. Fogarty passed at shoulder level but could not be passed into the central circulation. Performed fistulogram. Shows occlusion of cephalic vein before it entered the subclavian. Brought up a catheter & could get through the obstruction to the superior vena cava. Passed catheter beyond that, pulled the wire & performed imaging which confirmed patency of the proximal left brachiocephalic vein and the superior vena cava. Angioplastied along the length of the area that appeared abnormally narrowed, several inflations were performed, followup imaging revealed recanalization of the cephalic vein arch, resolution of the stenosis, good flow through the left brachiocephalic vein & the superior vena cava. There was now reflux into axillary vein distal to the cephalic arch." 36831 open, 36902-XU cephalic-peripheral. Do you feel the brachiocephalic was also angioplastied? (Procedure header states angioplasty of the left cephalic vein arch and of the left brachiocephalic vein)

36830

Greetings, A patient has a brachiocephalic fistula that is not functioning. The pt is taken to the OR and a thrombectomy is attemped. No dialator could be passed so the dialysis fistula is abandoned. A new graft is placed higher cephalic vein and tunneled with a end to end anastomosis on the arterial end. Is this a 36832 or a 36830? I'm thinking 36832. Thanks, LW

av shunt atherectomy, 37799

Dr's I'm totally in the dark on how to complete the coding this one. The patient has a malfunctioning upper arm brachiocephalic fistula with in-stent stenosis of the proximal cephalic vein and recurrent stenosis of the distal cephalic vein. Selective catheterization of the fistula with fistulagram was performed and then Silver Hawk atherectomy of recurrent stenosis within the cephalic venous stent, proximal vein followed by balloon angioplasty of the recurrent stenosis, distal cephalic vein. I coded 35476/75978/36147 for the balloon angioplasty of the distal cephalic vein, but frankly I am at a loss for how to code the atherectomy of the proximal cephalic portion of the fistula. 0237T atherectomy of brachiocephalic trunk doesn't seem correct. Would I use an unlisted code? Any advice would be greatly appreciated.

AV Fistula revision or new graft creation

I believe this is a revision of AV fistula (36832) with perhaps a -22 modifier appended; however, the surgeon wants to use 35011 and 36830. What are your thoughts?

"Indication for Surgery: Left forearm cephalic vein aneurysm, ESRD, degenerated left forearm AV fistula aneurysm. Surgical Procedure: Excision of aneurysmal left forearm cephalic vein, placement of a left forearm PTFE AV graft. Procedure: A long elliptical was incision made along forearm cephalic vein that was aneurysmal; it incorporated the degenerated overlying skin as a long skin paddle. Cephalic vein was dissected free, clamped, and divided. Aneurysmal segment of cephalic vein was handed off as specimen. I then anesthetized a lateral curvilinear tunnel and passed a PTFE graft through the tunnel and created a beveled end-to-end anastomosis between the graft and the inflow cephalic vein at the wrist. The graft had a strong inflow pulse. Excess graft was trimmed and created an end-to-end anastomosis to the outflow cephalic vein at the proximal forearm. Graft had a strong thrill."

Aneurysm Excision Follow-Up Question

I would just to ask a follow-up question to question ID #4783. After the AV fistula aneurysm was excised, they didn't revise it anymore because the patient didn't need the dialysis access anymore. Do we still code that as revision even though the fistula wasn't revised? At the end of the case the fistula was nonfunctional or totally closed.

explore radial and cephalic in addition to fistula creation

Can you bill for the exploration part in addition to the fistula creation? "A transverse incision was made on the distal forearm, and the cephalic vein was dissected free from the surrounding tissue. Several branches were ligated and divided using 3-0 silk suture. Next the radial artery was exposed and examined. The radial artery was very small caliber, and I did not think it would be adequate for fistula creation. Therefore I examined the antecubital portions of the cephalic vein and brachial artery in the proximal forearm, and these appeared to be larger caliber and better candidates for fistula creation. The doctor then used the brachiocephalic for the creation of a fistula."

Brachiocephalic Artery

I have a case in which the catheter was placed in the right brachiocephalic artery and documented as below. "Right brachiocephalic artery: Cervical view: The catheter was advanced into the right brachiocephalic artery, and angiography was performed over the cervical region. The cervical view of the right brachiocephalic artery shows tortuous origin of the right common carotid artery and tortuous origin of the right subclavian artery. The origin of the right vertebral artery is not well visualized. There is no significant steno-occlusive disease noted." If the left subclavian was also selected and the left vertebral was viewed and documented, would I only report code 36225 (unilateral)? Or would I also be able to report code 36221 for the right side? 

Aneurysmal Arteriovenous Fistula

What CPT code is appropriate for the following example? "The larger of the two aneurysms was the venous cannulation site. Micropuncture kit was used to cannulate the fistula, which appeared to be brachiocephalic. Fistulogram was performed, which turned down to the axilla rather than showing the usual cephalic vein outflow. Glidewire was advanced with a Dorado balloon parked across the stenosis of about 85%; it was inflated at 10 atmosphere. Fistulogram showed improvement of stenosis. The catheter was then removed, and the hole in the fistula was closed with a clamp. A clamp was applied across the inflow of the fistula. The aneurysm was squeezed to remove most of the blood in it, and then the outflow was clamped as well. A longitudinal incision was made on the anterolateral aspect of the fistula, and a large amount of excess fistula wall was excised. The lumen was irrigated with heparinized saline, and the fistulotomy was closed longitudinally using running 5-0 Prolene. Flow was restored."

Endarterectomy w/fistula

I have an interesting case, and I'm wondering if you may have some insight. The patient was to undergo brachiocephalic arteriovenous fistula creation for dialysis access and required a brachial endarterectomy with a bovine patch angioplasty, to which the cephalic vein was then attached to create the fistula. I know in lower extremity bypass procedures the inflow/outflow would be inclusive, but this is not technically a bypass procedure. It has no NCCI edit per Craneware. However, since code 36821 has a "separate procedure" designation, I hesitate to bill these together, as they are in the same anatomic site at same session. If only one code is determined to be billable, could I bill the endarterectomy since this is more extensive (higher RVUs) than the fistula creation (36821), even though the intent of the operative session was for creation of the fistula?

36832 vs 37607

Is this considered a revision or a ligation of the AV fistula?

"Intraoperative ultrasound was used to visualize the arterial anastomosis. An oblique incision was made with a scalpel, and the incision was deepened with electrocautery and metzenbaum scissors until the brachial artery and fistula were both identified. The artery and fistula were both confirmed to be as such with Doppler. A 6 mm Dacron tube graft was brought onto the field, opened with metzenbaum scissors so that it was formed into a patch instead of a tube, and wrapped around the proximal fistula for sizing. This was then sutured into place sizing the fistula to the graft with interrupted 5-0 prolene suture. A palpable thrill was still noted over the fistula. Hemostasis was obtained with electrocautery. The wound was closed with 3-0 vicryl, 4-0 monocryl, and skin glue. A radial pulse was palpable on completion."

Removal of Aneurysmal Angioaccess Arteriovenous Fistula

Please advise if code 36832 is appropriate for the following scenario: "The patient has a functioning brachiocephalic fistula and presents for excision of a severely aneurysmal radiocephalic fistula. The radial artery proximal and distal to the anastomosis was dissected out and controlled with vessel loop. The radial artery proximal to the fistula was noted to be severely dilated. The excision was extended along the length of the fistula to the antecubital fossa, and the aneurysmal radiocephalic fistula was exposed. The fistula was then dissected out to free up its adhesions to the overlying subcutaneous tissue. There were multiple branches that were hypertrophied and were suture ligated. The cephalic vein was amputated at the antecubital fossa and oversewn proximally. The aneurysmal fistula was then freed up from underlying adhesions all the way to the wrist. There were multiple crossing veins, which were hypertrophied and required ligation. The aneurysmal anastomosis was taken down, and the radial artery was ligated."

36832 or 37799 IJ vein to Cephalic Vein bypass of AV Fistula outflow tract

Patient with brachiocephalic AVF has a crushed stent in the subclavian vein, which is causing issue with outflow. The physician performed a bypass of the subclavian vein by placing a PTFE graft from the cephalic vein at the level of the shoulder to the internal jugular vein. The AV fistula venous anastomosis was not recreated or altered in any way. Would the below be considered a revision of the AV fistula (36832) or a vein-to-vein bypass (37799)? 

"The dorsal surface of the cephalic vein was incised with a #15 blade scalpel, and this was extended proximally and distally with Potts scissors. The 8 mm PTFE graft was spatulated. We performed an end-to-side anastomosis with 5-0 prolene suture. We turned our attention to the distal anastomosis within the internal jugular vein. Again, a #15 blade scalpel was used to incise the skin. The jugular vein was exposed and skeletonized. A venotomy was performed to construct an end-to-side anastomosis. The bypass graft was again spatulated in order to fit the venotomy."

37607 vs. 37799

I know that code 36832 is for revision. What code is appropriate for excision of AV graft/fistula that was created for dialysis? This graft/fistula is not infected, so I feel that code 35903 is not correct.

36831 or 36833?

Would thrombectomy of an AV fistula and stenting in the peripheral zone of the graft be considered thrombectomy with revision (36833) or thrombectomy without revision (36831)?

36833/36831

Would thrombectomy of an AV fistula and angioplasty in the peripheral zone of the graft be considered thrombectomy with revision (36833) or thrombectomy without revision (36831)?

Bilateral Dialysis Circuit Interventions

"Patient has a previously placed right arm fistula that has not yet been used and no longer has a thrill. She also has a left arm fistula with a declining flow rate. Fistulogram was obtained of the LUE. The venous anastomosis and occluded native brachial vein were balloon angioplastied. The right arm was separately accessed, fistulogram was performed, and the segment of the brachiocephalic fistula toward the upper humerus was balloon angioplastied." We coded this procedure as 36902-RT and 36902-59LT, but it was denied by Medicare. I looked at changing this to 36902-50, but my resources are showing that modifier -50 is not allowed with this code. Are the dialysis circuit interventions billable as bilateral procedures?

Revision of AV fistula vs creation of new fistula

Hi Dr. Z - I have a case in which the MD is calling a revision of an AV fistula (36833) but I think it is a creation of a new fistula (36830). Additionally, I am not certain if the diagnostic venogram performed via cutdown at the cephalic vein would be reported as 36147, 75791 or 75820. The H&P indicates that the old fistula is a left radial cephalic AV fistula which has occluded. The procedure is as follows: "Findings: 1. a newly created graft was constructed with good flow noted…findings of the upper extremity cephalic vein showed it to be a short course vein with occlusion. INdications: This patient presented with ESRD and underwent AV fistula which failed. He presents for revision…Procedure: …US was used to find the patients old AV anastomosis…I could not find any portion on tracking that was not clotted. In light of that I made a cut down over the cephalic vein at the antecubital fossa, dissected out for a short distance, and then cannulated this…venogram showed cephalic vein occlusion but a reasonable upper extremity brachial vein for access. Central venous runoff was w/o occlusion. With this in mind, I elected to convert to a new graft and continued the incision up into the upper arm to expose the brachial artery. With dissection the brachial artery carried out and the brachial vein was dissected through an upper arm incision in the deep fascia and mobilized for anastomosis. A tunnel was created and a flixene graft passed through the tunnel. The venous end of the graft was cut a venotomy was performed and the graft spatulated and sewn end to side to the venotomy…the arterial end was then approached. The brachial artery was opened…the end of the graft was sewn end to side to the artery...". Thanks in advance for your help!

Congenital heart cath with angiogram of the brachiocephalic

Should the following congenital heart cath be coded 93533 and 93567? Or 93531 and 36221? Would we need more documentation of the specific vessels visualized to submit code 36221? "Patient has a history of a large VSD, a PDA, LAD coronary artery to RV fistula. A catheter was advanced to the right heart, and a pressure and saturation sweep was performed. The Wedge catheter was also advanced across the atrial septum to the left lower pulmonary vein where pressures and saturations were recorded. A careful pullback from the LV to the descending aorta was performed using a Pigtail catheter. The catheter was placed in the aorta, and two angiograms were performed in the aortic root. Aortic Root: Two angiograms via the Pigtail catheter demonstrate the aortic root and left arch with normal brachiocephalic branching pattern. Both angiograms demonstrate the coronary artery branching patterns, without specific evidence of coronary artery fistula."

36821

Dr Z, I am not sure if the procedure described in the below op report would be considered a revision or new creation and whether or not the ligation of the collateral vein can be reported separately. Any clarification you can provide is appreciated. A patient has a nonmaturing distal radial AV fistula who came for evaluation. The fistula was cannulated and shuntogram performed (36147). The vein immediately after the anastomoses showed significant stenosis with flow through through collaterals with no flow through the main fistula. Arterial anastomosis was found to be adequate but the radial artery was small in caliber. Ligation of fistula performed and a portion of the cephalic vein more lateral and superior in location is found to be adequate and dissected proximally and distatlly with the side branches of the same being ligated. The vein is then cannulated and venogram of the upper extremity as well as central venous and SVC performed. Other than the cephalic vein being small, no stenosis or obstruction noted on studies. Dissection of radial artery was then performed and a longitudinal arteriotomy wsa performed. An angioplasty in the proximal portion of the artery was performed followed by angioplasty of the cephalic vein. (No codes as I believe angioplasties were done due to the finding they were small vessels and would be considered part of the revision or creation of the fistula.) The anastomosis of the two were performed in an end-to-side fashion (36821 or 36832 - creation vs revision). Once completed, flow was obtained. Incision is closed. There is a collateral branch arising from the cephalic vein that was visualized on angiogram. A separate incision was performed and vessel ligated (37607?).

Coding for revision versus creation of a fistula

Q. is this a revision or a creation? My doc says a revision I think a new fistula. PROCEDURE IN DETAIL: The patient was taken to the Operating Room and placed in the supine position. Following smooth induction of general anesthesia, the left arm, hand and upper arm were prepped with Chloraprep solution and draped with sterile linens. The incision at the elbow was opened, and a small amount of serosanguineous fluid was evacuated. The vein was identified, and there was no intraluminal clot and there was no pulse when it was totally occluded. The vein was clamped and divided just at the level of the previous vein anastomosis, and there was good backbleeding. The vein was flushed with heparinized saline and clamped. The deep artery was located at the base of the incision and mobilized for about 2 cm. The patient was given 3,000 units of Heparin intravenously. The artery was clamped and opened obliquely. An end-to-side anastomosis was fashioned with interrupted #6-0 Prolene and medium AnastoClip staples. The clamps were released, and there was an excellent thrill and minimal pulse. There was a palpable pulse at the wrist. The incision was closed with #3-0 Vicryl and steri-strips after the stump of the vein had been oversewn with #6-0 Prolene. The patient tolerated the procedure well.