Cardiology Coding Alert

Distinguish between fistula creation and anastomosis.

In some cases, your cardiologist may need to create an arteriovenous fistula (AVF) to provide vascular access for hemodialysis patients. Always check the documentation for details such as whether your cardiologist performed an open or percutaneous creation of an AVF.

Read on to learn more.

Tip 1: Mark Down Open Fistula Creation Codes

You have the following two choices when your cardiologist performs open creation of an arteriovenous fistula:

• 36825 (Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); autogenous graft)
• 36830 (Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); nonautogenous graft (eg, biological collagen, thermoplastic graft)

During a 36825 procedure, your cardiologist will make an incision over the target area and surgically create an arteriovenous fistula — a connection between an artery and a vein. Code 36825 describes an open procedure that uses an autogenous vein graft from elsewhere in the patient’s body to create a direct, end-to-end anastomosis graft connecting the desired artery and vein.

Code 36830 describes a similar procedure, except the graft material is not a vein from the patient’s body. Instead, the cardiologist uses a nonautogenous graft that is a synthetic material made up of biological collagen fibers or thermoplastic.

Tip 2: Learn More About New Percutaneous Fistula Creation Codes

You gained the following two new codes this year for percutaneous fistula creation:

• 36836 (Percutaneous arteriovenous fistula creation, upper extremity, single access of both the peripheral artery and peripheral vein, including fistula maturation procedures (eg, transluminal balloon angioplasty, coil embolization) when performed, including all vascular access, imaging guidance and radiologic supervision and interpretation). This procedure entails single access into a peripheral artery and peripheral vein, according to CPT^®.
• 36837 (Percutaneous arteriovenous fistula creation, upper extremity, separate access sites of the peripheral artery and peripheral vein, including fistula maturation procedures (eg, transluminal balloon angioplasty, coil emboli­zation) when performed, including all vascular access, imaging guidance and radiologic supervision and interpretation). This procedure entails two separate access sites to the peripheral artery and peripheral vein, per CPT^®.

Report 36836 when your cardiologist uses single access for both the peripheral artery and vein. On the other hand, report 36837 when your cardiologist uses separate access sites for the peripheral artery and vein.

Coding tip: Limit the use of 36836 and 36837 to upper extremity procedures, such as those involving the brachial artery and basilic vein.

Don’t miss: “Codes 36836 and 36837 include all vascular access, angiography, imaging guidance, and blood flow redirection or maturation techniques (e.g., transluminal balloon angioplasty, coil embolization) performed for fistula creation,” per the CPT^® guidelines.

“The Centers for Medicare and Medicaid Services (CMS) released the final rule on November 1, 2022. In it, CMS replaced HCPCS Level II arteriovenous fistula creation codes G2170 and G2171 with 36836 and 36837. Code 36836 utilizes a single access system (e.g., Ellipsys™),” says Robin Peterson, CPC, CPMA, manager of professional coding services, Pinnacle Integrated Coding Solutions, LLC in Centennial, Colorado. “During this procedure, a vein in the arm is accessed percutaneously and a catheter is passed through the vein wall into the proximal artery. A connection between the artery and vein is produced by thermal energy.”

Code 36837 utilizes a two-access system (e.g., WavelinQ-4F™) in which a catheter is inserted into the artery and a second catheter into an upper extremity vein, Peterson says. Guided by fluoroscopic imaging, magnets are used to hold the artery and vein together. Once in place, radiofrequency energy is used to create the connection between the artery and the vein to create a new opening for blood flow (AV fistula).

“If you are unsure about which technique was used based upon the physician’s documentation, query the provider requesting more detail about the technique used or the specific device utilized to complete the AV fistula,” Peterson says. “This will help you decide which code is the most accurate.”

Tip 3: Understand Arteriovenous Anastomosis Procedures

In some cases, rather than using a graft to connect the artery and vein, your cardiologist may create a direct connection using a procedure such as that described by 36821 (Arteriovenous anastomosis, open; direct, any site (eg, Cimino type) (separate procedure)).

Code 36821 also an open procedure, but the cardiologist creates side-by-side cuts in the vein and artery and directly attaches the two openings by a method such as sutures. That’s why a CPT^® note under 36825 directs you to use 36821 for “direct arteriovenous anastomosis.”

Other arteriovenous anastomosis procedures include the following:

• 36818 (Arteriovenous anastomosis, open; by upper arm cephalic vein transposition). Report 36818 when your cardiologist creates an arteriovenous anastomosis in the upper arm between the cephalic vein and the brachial artery.
• 36819 (Arteriovenous anastomosis, open; by upper arm basilic vein transposition). Report 36819 when your cardiologist creates an arteriovenous anastomosis in the upper arm between the basilic vein and the brachial artery.
• 36820 (Arteriovenous anastomosis, open; by forearm vein transposition). Report 36820 when your cardiologist creates an arteriovenous anastomosis by forearm vein transposition.

Anastomosis defined: Anastomosis is a connection between two (tubular) structures, anatomical or surgically created, such as between two blood vessels.