Arteriovenous Fistula Creation (Hemodialysis Access)
3682136819wRVU: 12.96 — AV anastomosis, open; by upper arm basilic vein transposition (brachiobasilic fistula, 12.96 wRVU, 90-day global — standalone primary code, not an add-on to 36821)36818wRVU: 12.08 — AV anastomosis, open; by upper arm cephalic vein transposition (requires 2 incisions with dissection and subcutaneous tunneling of cephalic vein to medial brachial artery; 12.08 wRVU, 90-day global — standalone primary, NOT for direct brachiocephalic anastomosis)36820wRVU: 12.74 — AV anastomosis, open; by forearm vein transposition (forearm procedure — transposition of forearm vein between elbow and wrist; 12.74 wRVU, 90-day global — standalone primary)36825wRVU: 13.82 — AV fistula by autogenous conduit graft (autologous vein conduit, e.g., saphenous; 13.82 wRVU, 90-day global — standalone primary)36830wRVU: 11.73 — Creation of AV fistula by nonautogenous graft (ePTFE or biological collagen graft; 11.73 wRVU, 90-day global — standalone primary)
End-stage renal disease requiring permanent hemodialysis access
Same
Left [right] [radiocephalic / brachiocephalic / brachiobasilic transposition] arteriovenous fistula creation
[Attending name], MD/DO
[Resident/PA name]
Local: [X] mL 1% lidocaine without epinephrine [/ regional brachial plexus block / MAC]
The patient is a [age]-year-old [male/female] with end-stage renal disease requiring permanent hemodialysis access. Pre-operative vein mapping demonstrated [cephalic / basilic] vein diameter of [X mm] and [radial / brachial] artery inflow. A [radiocephalic / brachiocephalic / brachiobasilic] AVF was selected. The risks, benefits, and alternatives including AV graft were discussed and informed consent was obtained.
The [cephalic / basilic] vein was identified and mobilized with adequate diameter [X mm] and quality. The [radial / brachial] artery was well-pulsatile. The anastomosis was constructed without tension. A thrill was palpable and bruit auscultated throughout the [forearm / upper arm] fistula upon completion. Doppler confirmed flow.
The patient was positioned supine with the ipsilateral arm extended on an arm board. The [wrist / antecubital fossa] was prepped and draped. Local anesthesia was infiltrated.
A longitudinal incision was made over the [radial artery at the wrist / brachial artery at the antecubital fossa]. The [cephalic / basilic] vein was identified, mobilized for [2-4] cm, and branches ligated. The artery was dissected and controlled.
The vein was spatulated to match the arteriotomy. A longitudinal arteriotomy [approximately 6-8 mm] was made. The end-to-side anastomosis was constructed using running [6-0 Prolene] suture. Clamps were released. A thrill was immediately palpable and a bruit audible throughout the fistula. Doppler confirmed flow.
The wound was closed in layers. A light dressing [not circumferentially compressive] was applied.
None
None
Minimal
None
The patient tolerated the procedure well. A thrill was confirmed at the anastomosis. The patient was instructed on fistula care and to return for fistula maturation assessment in [6-8 weeks]. Cannulation should not occur until documented maturation is confirmed at the 6-8 week assessment.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ESRD, hemodialysis access needed
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** AVF creation
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Local: *** mL 1% lidocaine without epinephrine
INDICATIONS: .PTAGE-year-old .PTSEX with ESRD. Vein mapping: *** mm cephalic/basilic, *** artery inflow. Consent obtained.
FINDINGS: Vein *** mm, adequate quality. Artery well-pulsatile. Thrill and bruit confirmed post-anastomosis. Doppler confirmed flow.
PROCEDURE:
Supine, arm extended on arm board. *** prepped and draped. Local anesthesia infiltrated. *** incision. Cephalic/basilic vein mobilized *** cm, branches ligated. Artery dissected and controlled. Vein spatulated. *** mm arteriotomy. End-to-side anastomosis with running 6-0 Prolene. Clamps released; thrill palpable, bruit audible, Doppler confirmed. Wound closed in layers, light non-compressive dressing.
EBL: Minimal
COMPLICATIONS: None
DISPOSITION: Thrill confirmed. Maturation assessment in 6-8 weeks. No cannulation until maturation documented.
Signed: .ME, .MYDEGREE
.TODAYVariants
AV Graft (Prosthetic, Vein Unsuitable)
Given inadequate vein caliber [<2.5 mm] on pre-operative mapping, a prosthetic AV graft was used. A [6 mm] ePTFE loop graft was tunneled in the [forearm / upper arm] in a [loop / straight] configuration. Proximal anastomosis was constructed end-to-side to the [brachial / radial] artery and distal anastomosis end-to-side to the [brachiobasilic / antecubital] vein. Thrill was confirmed throughout the graft. CPT 36830 (nonautogenous graft, 11.73 wRVU). AV grafts can be cannulated earlier than AVF (2-3 weeks) but have lower long-term patency.
Brachiobasilic AVF with Transposition
The basilic vein in the medial upper arm was exposed through a longitudinal incision, mobilized from elbow to axilla, ligated and divided distally. The vein was transposed through a subcutaneous tunnel to the lateral arm surface to allow dialysis cannulation access. The proximal end was anastomosed end-to-side to the brachial artery. Thrill confirmed throughout. CPT 36819 (12.96 wRVU). A two-stage approach (Stage 1: brachio-basilic anastomosis without transposition; Stage 2: superficialization at 6 weeks) may be preferred for small-diameter basilic veins to allow maturation before transposition.
Charting Tips
- Document that a thrill is palpable and bruit is audible at the end of the case. Absent thrill immediately post-operatively indicates technical failure and should prompt intraoperative revision rather than post-operative discovery.
- Record vein diameter and artery caliber from pre-operative duplex mapping in the note. The rule of 6s for AVF maturation requires: (1) vein diameter ≥6 mm, (2) depth ≤6 mm from skin, (3) straight segment ≥6 cm long, and (4) flow >600 mL/min. Document pre-op measurements to establish expected maturation potential.
- Document the no-compression dressing instruction and timeline for fistula use. Premature cannulation and inadvertent compression are the two most preventable causes of early fistula failure.
- ICD-10: N18.6 (ESRD) is the primary code; Z99.2 (dependence on renal dialysis) is coded as an additional code when the patient is already receiving dialysis. Both are required for CMS ESRD quality metric reporting.
Billing Tips
- 36821 (AV anastomosis, direct, any site, 11.60 wRVU, 90-day global) covers radiocephalic (Brescia-Cimino) fistula at the wrist AND direct brachiocephalic anastomosis at the antecubital fossa — both are direct anastomoses and both use 36821. The word 'direct' in the descriptor is what distinguishes it from transposition codes.
- Upper arm fistulas requiring vein transposition are coded by the vein used: 36818 (cephalic vein transposition, 12.08 wRVU) requires two incisions and creation of a subcutaneous tunnel; 36819 (basilic vein transposition, 12.96 wRVU) requires medial upper arm exposure, mobilization from elbow to axilla, and tunneling. Do NOT use 36818 for a direct brachiocephalic anastomosis — that is 36821. 36820 (forearm vein transposition, 12.74 wRVU) is a forearm procedure, not an upper arm code.
- Prosthetic AV graft: 36830 (nonautogenous graft, e.g., ePTFE; 11.73 wRVU); autologous conduit graft: 36825 (13.82 wRVU). Document graft material (ePTFE, bovine carotid artery/Artegraft, early-cannulation graft/Gore Acuseal) and configuration (loop vs. straight). Dacron is not used for dialysis access grafts.
- Global period is 90 days. Post-op fistula mapping, ultrasound surveillance, and routine follow-up within 90 days are bundled. Fistulogram and angioplasty for stenosis are separately billable with modifier -58 (planned staged procedure within global) or -79 (unrelated procedure after global). Use -78 only for unplanned return to OR for a complication.
- ESRD Network reporting: for Medicare patients on dialysis, document that the patient has ESRD and this is a dialysis access creation. This is required for CMS ESRD quality metrics.
- Ligation of side branches (accessory vein coil or ligation) performed at the same session is bundled. Do not bill separately.
- Document: vessel selected (radial/brachial artery, cephalic/basilic vein), whether transposition was performed, anastomosis configuration (end-to-side), venous diameter on pre-op mapping, thrill/bruit and Doppler confirmation at end of case, and estimated maturation timeline.
General coding reference. Verify with your institution’s billing department before submitting claims.