Wiki Arteriovenous Anastomosis for Hemodialysis Access

[AlisonFaught]

Vascular surgery coders please help! I have a payer requesting recoupment on CPT code 36820, stating that the medical record indicates creation of fistula between antecubital vein and radial artery was a Direct anastomosis and not a transposition of the vein. I showed the surgeon the Encoder descriptions of the CPT codes that I have to choose from (36818-36821) - he said they are like descriptions of procedures that aren't even done anymore . . . He said 36820 sounds the most like what he did. He said that he moved the deep communicating vein from the deep vessel system to the superficial system in order to anastomose it to the radial artery. This was all done through 1 transverse incision just distal to the antecubital crease. He also said this is not a Cimino type procedure, as it is a end-to-side anastomosis and not side-to-side. I told him that, from what I can tell, the type of anastomosis does not matter for CPT code assignment. Everything I have read about 36820 says it is for all possible constructions of forearm vein transposition, but Encoder says the vein is inverted end to end (between the elbow and wrist per CPT assistant) making me think a longitudinal incision is required for this CPT code . . . Or can it really be used in this instance, where the surgeon is saying he dissected the vein out of the deep system and moved it to the superficial system (although maybe this could be a bit clearer in the Op note)? OP Note attached.