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Hemodialysis Procedures


AV anastomosis by upper arm cephalic vein transposition (CPT code 36818) includes tunneling of a portion of the vein for anastomosis with the brachial artery.  The surgeon may call this procedure brachiocephalic vein transposition. The procedure requires two upper arm incisions:  one medial over the brachial artery and the other lateral to expose a portion of the vein. A tunnel is created between the incisions, and complete dissection of a substantial portion of the cephalic vein is required to allow it to be moved to a more superficial location and pulled through the tunnel for anastomosis with the brachial artery on the medial aspect of the upper arm.

 

AV anastomosis by upper arm basilic vein transposition (CPT code 36819) is similar to 36818 but with transposition of the basic vein and may be documented as a brachiobasilic vein transposition.

 

Image of brachiocephalic vein transposition

http://www.nature.com/ki/journal/v62/n4/full/44932 06a.html



AV anastomosis by forearm vein transposition (CPT code 36820) is used to report venous transposition between the elbow and wrist. This procedure is also similar to upper arm vein transposition 36818 or 36819.

 

AV anastomosis, direct, any site (CPT code 36821) is used to report a direct anastomosis between an artery and a vein to create a direct autogenous hemodialysis access.  This procedure does not require multiple incisions, transposition of the vein, or creation of a tunnel. Can be radial/cephalic (see next image), brachial/cephalic, proximal radial-median antebrachial (forearm).


Image: http://www.nature.com/ki/journal/v62/n4/full/44932 06a.html



Codes 36825 and 36830 are for arteriovenous fistulas created with a graft. A tube is created that is surgically tunneled underneath the skin to connect the artery to the vein.  36825 uses donor vein, 36830 uses synthetic vein, such as Gortex or PTFE.

AV grafts can become occluded and require a therapeutic intervention to restore optimal function to the graft. 36831, 36832 and 36833 are open procedures. 36831 includes thrombectomy only. In a thrombectomy, the fistula/graft is opened via an incision, a catheter is inserted into the fistula and the clots are extracted. 36832 includes revision only.  A revision might be a patch angioplasty. The fistula or graft may be opened in order to straighten a kink or remove a clot and re-anastomose the graft. Another indication may be scar formation that has stenosed the fistula. 36833 inclues revision and thrombectomy.

AV grafts are most commonly treated by percutaneous angioplasty or thrombectomy. 36870 is a percutaneousthrombectomy. According to CPT Assistant, there are many ways to percutaneously remove a thrombus from a dialysis access site. Examples of current methods are pharmaceutical thrombolysis (including pulsed spray, lyse-and-wait, short infusions (typically one hour or less) and longer infusions) and various types of mechanical maceration or clot removal. The code is designed to cover any of these methods or combinations of these methods and is used only to describe the actual procedure of removing thrombus from the access and restoring flow. When these accesses thrombose, most develop what is termed an "arterial plug," or a small densely fibrotic clot, at the arterial anastomosis, that typically will not dissolve and which usually sticks in the graft, narrowing or occluding the arterial inflow. This code also describes removal of this portion of the thrombus, which usually requires an additional step for removal separate from the rest of the procedure to declot the graft.
 
For pharmaceutical thrombolysis, the thrombosed graft is typically accessed using one or two catheters or intracatheters to allow instillation of a thrombolytic drug directly into the thrombus. The drug may be delivered in a bolus, as "pulse spray" with manual bursts of drug delivered through a catheter, or as an infusion through a catheter. Pharmaceutical thrombolysis typically dissolves the majority of the thrombus. The rest is treated using mechanical means such as balloon inflation to compress or dislodge the thrombus. The arterial plug is typically removed by partially inflating a balloon at the arterial anastomosis and pulling the balloon into the graft, which pulls the arterial plug into the graft. The plug is then further treated with maceration or dislodgment from the graft.
 
For mechanical thrombolysis, the thrombosed graft is typically accessed with direct puncture. Sheaths are placed into the graft to facilitate introduction of the thrombectomy device and the device is activated and passed through the thrombus until the thrombus is macerated and/or removed. Mechanical thrombolysis may also be accomplished without use of devices made specifically for this purpose. Small Fogarty-type balloons are another example of a type of device that may be used for this purpose.

Percutaneous thrombectomy might include a balloon used to compress or dislodge the thrombus but does not include balloon angioplasty (typically done for vessel stenosis). Do not code 36870 more than once regardless of the number of methods used to remove the clot from the graft. The percutaneous thrombectomy code does not include:

  • puncture of the graft with radiologic evaluation of the access (36147)
  • venous angioplasty (35476)
  • stent placement (37205)
  • arterial angioplasty (35473 - 35475)
  • pharmaceutical thrombolysis performed outside the graft (37201)
Percutaneous transluminal angioplasty (PTA) eliminates areas of narrowing or occlusion in the graft. During PTA, a balloon catheter is inserted through the skin into a vessel to the site of the narrowing. Use the angioplasty code once even if more than one stenosis is treated within the fistula/graft (at the anastomosis or in the outflow vein in the arm). According to an article published in AHIMA, although there are two separate codes to describe angioplasty at the arterialanastomosis and the venous anastomosis, only one of these codes may be assigned per encounter. This is consistent with advice from the Society of Interventional Radiology, which considers the entire graft from the arterial anastomosis through the venous anastomosis, as well as the outflow vein approximately to the level of the axillary vein, a single vessel. Most payers consider AV graft procedures venous procedures, and these interventions are usually coded as such. Arterial stenosis is not commonly found but may be present and may be the flow limiting cause of acute thrombosis of the graft.

If a separate vessel from the initially treated stenotic vessel is involved, such as the subclavian vein, PTA of that lesion should be coded.

Central veins or central zone for reporting AV shunt interventions

  • upper extremity:  subclavian and brachiocephalic veins and superior vena cava
  • lower extremity:  common iliac vein and inferior vena cava
Peripheral zone

  • Arterial anastomosis, intragraft, venous anastomosis, and outflow veins up to and including the axillary vein (upper extremity) or common femoral/external iliac veins (lower extremity) (peripheral veins).
Venoplasty and stent placement are reported only once per treatment "zone" regardless of the number of lesions or veins treated in each zone. When arterial angioplasty and venoplasty are performed in the same peripheral zone, only CPT codes 35476/75798 are reported.

Disclaimer: All articles intended for general guidance only and not as a recommendation for a specific situation. Readers should consult an official source (AHA, AMA, etc.) or a qualified attorney for specific legal guidance.

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