General Surgery Coding Alert

See how procedure and payer may guide correct code choice.

Two new fistula creation codes go into effect Jan. 1, 2023, but will you be ready to distinguish those procedures from existing, similar codes?

We have the lowdown on the new codes, plus a rundown of existing HCPCS Level II and CPT® codes to help you hone your coding for these procedures.

Purpose: Surgeons may create an arteriovenous fistula (AVF) to provide vascular access for hemodialysis patients.

Terminology: As you compare the fistula creation codes, keep the following terms in mind:

• Fistula: Abnormal passageway between two structures, such as between two vessels.
• Anastomosis: Connection between two (tubular) structures, anatomical or surgically created, such as between two blood vessels.

Master New Percutaneous Fistula Creation Codes

You’ll see the following two new codes in CPT^® 2023 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)
• 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)

Difference: You’ll use 36836 when your surgeon uses single access for both the peripheral artery and vein. On the other hand, you should use 36837 when your surgeon uses separate access sites for the peripheral artery and vein.

“The new fistula creation codes, 36836 and 36837, are for a non-surgical, minimally invasive procedure, which allows for a shorter healing time,” says Robin Peterson, CPC, CPMA, manager of professional coding services, Pinnacle Integrated Coding Solutions, LLC in Centennial, Colorado. “When reviewing this procedure documentation, expect to see both an arterial catheter and a venous catheter inserted either through an incision or percutaneous access. Each catheter has a magnet, which then aligns while pulling the vessels together. One catheter will deliver a radiofrequency burst of energy and create the connection between the two vessels.”

Tip: Limit the use of these codes to upper extremity procedures, such as those involving the brachial artery and basilic vein.

Contrast Existing Open Fistula Creation Codes

CPT^® already includes the following two codes for arteriovenous fistula creation that describes open, rather than percutaneous, procedures:

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

For 36825, the surgeon makes an incision over the target area and surgically creates an arteriovenous fistula, which is a connection between an artery and a vein. This code 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.

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

Different: Rather than using a graft to connect the artery and vein, surgeons 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)). This is also an open procedure, but the surgeon 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.”

Compare HCPCS Level II Codes

For Medicare payers, you’ve had the following two codes since 2020 to report percutaneous AVF creation:

• G2170 (Percutaneous arteriovenous fistula creation (AVF), direct, any site, by tissue approximation using thermal resistance energy, and secondary procedures to redirect blood flow (e.g., transluminal balloon angioplasty, coil embolization) when performed, and includes all imaging and radiologic guidance, supervision and interpretation, when performed)
• G2171 (Percutaneous arteriovenous fistula creation (AVF), direct, any site, using magnetic-guided arterial and venous catheters and radiofrequency energy, including flow-directing procedures (e.g., vascular coil embolization with radiologic supervision and interpretation, when performed) and fistulogram(s), angiography, veinography, and/or ultrasound, with radiologic supervision and interpretation, when performed)

Both of these codes describe percutaneous arteriovenous fistula creation. The distinction between the two codes depends on the method the surgeon uses. That means you must carefully check the medical documentation when your surgeon performs these procedures to ensure that you choose the correct code.

For the G2170 procedure, the surgeon percutaneously accesses the site and advances a catheter tip to the desired location where the artery and vein meet and activates low-power thermal energy to cut the vessel walls and create a fused anastomosis, allowing blood to flow between the two vessels. The procedure includes angiography to assess blood flow, and the surgeon may perform additional services to optimize flow, such as using a transluminal balloon angioplasty to widen a vessel or occluding supply of a vessel with a coil device (coil embolization).

Code G2171 describes a different percutaneous procedure using two separate magnetic catheters for the vein and the artery. Once properly positioned, the magnets bring the vessels side by side and a radiofrequency electrode creates a hole in the adjoining vessels and sears them together, creating an AVF. As with G2170, the surgeon may perform additional services to optimize flow.

Remember: “Codes G2170 and G2171 describe percutaneous AVF creation at any anatomic site, while new codes 36836 and 36837 describe only upper extremity services,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, product manager, MRO, in Philadelphia.

Key: Medicare payers may continue to require that you report the appropriate HCPCS Level II codes for your surgeon’s work. Check with your payer for details.