excision of aneurysmal arteriovenous fistula


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Should this be coded as 35206, 37607, 36821? I feel like this might be more of a revision of the old fistula with creation of a new fistula and that 36832, 36821-59 might be better.

The physician excised an aneurysmal radiocephalic fistula, then created a new brachiocephalic fistula.

Transverse incision made 1 cm below antecubital crease. cephalic vein identified and dissected circumferentially. a branch was selected for use. the distal vein was ligated and divided. bicipital aponeurosis was opened and the distal brachial artery was dissected out.

Elliptical incisions were made around each aneurysmal site in the forearm, small branches were ligated and divided. segments in the forearm were ligated and divided and handed off. the segment near the arterial anastomosis was dissected down to the radial artery.

The radial artery was clamped, the aneurysmal portion of the fistula was excised leaving a cuff of tissue over the radial artery, then the cuff of tissue was closed to reform the radial artery. Flow to the radial artery was restored.

The deep branch of the cephalic vein was now ligated and divided and the vein was brought over to the (distal brachial) artery. The artery was clamped proximally and distally and an arteriotomy was made.An end to side anastomosis was sewn between the vein and artery.
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same scenario

I have the same case. and found this - AV fistula ligation and repair of left bracial artery - Coding Clinic for HCPCS - Third Quarter 2013 Page: 4
The patient presented with an enlarged aneurysmal area near the anastomosis to the brachial artery. Since she is post-renal transplant and is no longer on dialysis, a decision was made to also excise the fistula.
What is the code for the excision of the aneurysm, takedown of the fistula and primary repair of the left brachial artery? Would these procedures be included in CPT code 35236, Repair blood vessel with vein graft; upper extremity, as described in Coding Clinic for HCPCS, 4th Quarter, 2011, Pages 7-8?
A "takedown" of the arteriovenous (AV) fistula implies ligation of the AV fistula and arterial repair. Based on the documentation submitted with your request, the arteriovenous fistula was ligated and the aneurysmal area was near the anastomosis; therefore, it would be appropriate to report CPT code 37607, Ligation or banding of angioaccess arteriovenous fistula, for the procedure performed. In this case because the artery itself was not involved in the aneurysm, CPT code 35206, Repair blood vessel, direct; upper extremity, would be reported for the primary repair of the left brachial artery. If the artery were repaired with a vein patch, CPT code 35236 would be reported instead of CPT code 35206.
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