Arteriovenous Fistula Creation (Hemodialysis Access)

CPT 36821 · 11.6 wRVU · 90-day global

CPT36821

wRVU11.6

Global90-day

ApproachOpen

ComplexityComplex

Add-on / Variant CPTs

36830 wRVU: 11.73 — Creation of AV fistula by other than direct arteriovenous anastomosis (prosthetic graft)
36818 wRVU: 12.08 — AV anastomosis, open; transposed forearm vein to forearm artery

Preoperative Diagnosis:

End-stage renal disease requiring permanent hemodialysis access

Postoperative Diagnosis:

Same

Procedure Performed:

Left [right] [radiocephalic / brachiocephalic / brachiobasilic] arteriovenous fistula creation

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

Local: [X] mL 1% lidocaine without epinephrine [/ regional brachial plexus block / MAC]

Indications:

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.

Findings:

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.

Description of Procedure:

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 [X] cm, and branches ligated. The artery was dissected and controlled.

The vein was spatulated to match the arteriotomy. A longitudinal arteriotomy [approximately 1 cm] 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.

Complications:

None

Specimens:

None

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

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]. Dialysis should be initiated through the fistula no sooner than 4–6 weeks post-operatively.

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

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.

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. *** cm arteriotomy. End-to-side anastomosis with running 6-0 Prolene. Clamps released; thrill palpable, bruit audible, Doppler confirmed. Wound closed in layers, light dressing.

EBL: Minimal
COMPLICATIONS: None
DISPOSITION: Thrill confirmed. Maturation assessment in 6–8 weeks. No cannulation for 4–6 weeks.

Signed: .ME, .MYDEGREE
.TODAY

Variants

AV Graft (Prosthetic, Vein Unsuitable)

Given inadequate vein caliber [<2 .5 mm]< span> on pre-operative mapping, a prosthetic AV graft was used. A [6 mm] PTFE 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. 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. The transposed vein is typically deeper and smaller diameter than cephalic vein and may require 8–12 weeks for maturation.

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 vein diameter ≥6 mm, depth ≤6 mm, and length ≥6 cm. Documenting pre-op measurements establishes the 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.

Billing Tips

36821 (direct AV anastomosis any site, 11.60 wRVU) is used for radiocephalic (Brescia-Cimino) fistula at the wrist, which is the most common primary access.
Upper arm fistulas: 36818 (brachiocephalic, 12.08 wRVU), 36819 (brachiobasilic transposition, 12.96 wRVU), 36820 (forearm vein transposition, 12.74 wRVU). Document the specific vein used and whether transposition was required.
Prosthetic AV graft: 36830 (nonautograft loop or straight, 11.73 wRVU); autogenous conduit graft: 36825 (13.82 wRVU). Document graft material (ePTFE, Dacron, saphenous vein conduit).
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 use modifier -79 (unrelated) after the global or -78 (complication) within the global.
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/brachial vein), anastomosis configuration, venous diameter on pre-op mapping, thrill/bruit at end of case, and estimated maturation timeline.

ⓘ General Billing Tips →