Ask Dr. Z

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."