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BABS37

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av fistula creation 36825 or 36821?

Patient came in for a left upper extremity AV fistula creation. It sounds like he did 36821 even though its a creation which would be 36825... I don't know which to choose and why. Can anyone help?

...Incision was made overlying the radial artery pulse. The radial vein in the forearm was measured with ultrasound at 5.5mm and felt to be of good caliber without intraluminal debris. Dissection was carried over towards this and it was isolated out. Collateral branches were ligated with 3-0 silk on the venous side and clips on the collateral side immobilizing the vein of adequate length. It was then clipped distally and amputated. It was flushed proximally with Heparinized saline and the occluded with a bulldog clamp. The radial artery was then dissected out and surrounded with vessel loops proximaly and distally. The readial artery was flushed with heparainized saline and a longitudinal arteriotomy was made with an 11 blade and extended with potts scissors. The vein was spatulated and tehn attached to the artery to create the running anastomosis with 6-0 prolene. Loops and clamps were released and there was a palpated thrill in the venous limb with good flow...

That surgery was in the am... then he goes back in that night because the op site was bleeding-

...the left arm was prepped and draped sterily. The previous incision site was opened revealing a large amount of clotted blood which was evacuated with suction and irrigation. A miniscule bleeding point ws noted on teh anterior surface of teh venous limb of the fistula and felt to be a tiny collateral off the vein which opened up in the recovery area. This was ligated and sewn. The remainder of the op field was carefully irrigated and explored for additional bleeding. Thrombin on pledgets was placed over these areas and left in place for five minutes then removed. The wound was irrigated and observed and no additional bleeding was seen....

So I thought since the first one was spatulated that that would qualify it for 36821 but not sure but then that throws me off for my second code on the second surgery- 36831, 36832, or 36833? Plus, do I use 79 and an unrelated procedure or 78 for a related procedure but unplanned? SO confused!!!!
 
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cmartin

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I think your 2nd one is really a 35860 (Exploration for postop hemorrhage, thrombosis or infection; extremity), as the problem was outside of the actual fistula itself, and the modifier would definitely be a 78. For the first one, it's confusing because he says the vein was amputated, which sounds as tho he's going to do a 36825, but then says a longitudinal arteriotomy was made, vein spatulated & attached in a running anastomosis, with no mention of attachment to another vein, so THAT sounds like 36821 after all.
 
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