Fistula First Breakthrough Initiative Provides Roadmap to Reach Goal of 66%

The Fistula First Breakthrough Initiative (FFBI) has released a strategic plan for achieving the Center for Medicare & Medicaid Services’ (CMS) goal that two-thirds (66 percent) of prevalent hemodialysis patients will use an arteriovenous (AV) fistula as their primary method of vascular access.

At the end of 2005, 41 percent of prevalent patients on hemodialysis were dialyzed with a fistula, up from 33 percent in 2003. By May 2009, this percentage had increased to 52.6 percent (179,113 patients). CMS says it hopes to improve fistula use rates to levels seen in Europe and Asia, on average 70 percent and 80 percent, respectively.

To achieve that goal, the FFBI Strategic Plan focuses on seven strategies and two policy recommendations.

Led by the FFBI Coalition, with support from the ESRD Network Organizations and the Quality Improvement Organizations (QIOs) under CMS’ leadership, the strategic plan includes the following concepts:

  1. Nephrologist as Leader: Encourage and support nephrologists to take a leadership role and be accountable for vascular access management in all hemodialysis patients.
  2. Leveraging Partnerships: Partner with organizations to improve AV fistula placement and utilization rates.
  3. Hospital Systems: Modify hospital systems to promote AV fistula placement.
  4. Patient Self-management: Promote patient self-management through the stages of chronic kidney disease.
  5. Addressing Access Problems: Promote fast-track protocols for rapid identification and referral of vascular access problems, which include failure to mature, revisions of the failing AV fistula, and failure to place an AV fistula.
  6. Practitioner Training and Credentialing: Promote training, experience, and credentialing of health care professionals in the area of hemodialysis vascular access management.
  7. FFBI Change Concepts: Expand and endorse the current change concepts for education and promotion throughout the renal, surgical, and interventional communities.

Hemodialysis is …

Hemodialysis is the most common treatment for end stage renal disease (ESRD). About 330,000 Medicare beneficiaries currently receive this treatment.

During hemodialysis, tubes are used to carry the blood between the body and the dialysis machine. This requires the patient to have an access to the bloodstream. For most patients the best access is a fistula. An AV fistula is the surgical joining of a vein and an artery usually in the forearm to provide an access for dialysis.

Fistulas are considered to be the “gold standard” for establishing access to a patient’s circulatory system. Fistulas last longer, need less rework or repairs, and are associated with lower rates of infections, hospitalization, and death.

Coding for Hemodialysis

Creation of an AV fistula for hemodialysis access is a surgical procedure reported with 36821 Arteriovenous anastomosis, open; direct, any site (eg, Cimino Type). Note that direct anastomosis differs from creation of an AV fistula with a graft, 36825 Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); autogenous graft (for a human tissue graft) or 36830 Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); nonautogenous graft (eg, biologica collagen, thermoplastic graft) (for a synthetic graft).

A graft allows quicker access (development of an AV fistula following direct anastomosis can take weeks to months), but increases the possibility for complications, such as thrombosis (clotting) and infection.

Coding for hemodialysis depends on the site of service and the reason for the service. Codes 90951-90970 report ESRD-related hemodialysis for outpatient settings. These codes are age-specific, and define services for a full month for outpatient (90951-90962) and home (90963-90966) dialysis services. Partial-month services (less than 30 days) are reported using 90967-90970.

For non-ESRD related hemodialysis, or for ESRD-related hemodialysis in the inpatient setting, turn instead to codes 90935-90940.

Read the FFBI Strategic Plan online. Learn more about CMS’ ESRD quality projects.

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