AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2013 Quarter 4; Ask the Editor
Stage II Cephalic Vein Transposition (Superficialization) of Arteriovenous Fistula
The patient is a 59-year-old female with end stage renal disease (ESRD), who had recently undergone formation of a right arteriovenous (AV) fistula stage I. She now presents for the second stage of the procedure. The surgeon documented, “right upper extremity cephalic transposition AV fistula.” During the surgery, a longitudinal incision was performed; the basilic vein was evaluated and found to be an unsuitable conduit. The cephalic vein was then exposed and the dissection was continued to the antecubital crease where the cephalic vein was of appropriate caliber. The antecubital incision was again re-incised and the anastomosis interrogated. The patient was heparinized and the vein transected. The vein was removed from its bed and tunneled in a subdermal fashion in a transposed manner. The anastomosis was then re-performed below the antecubital with Prolene suture. Flow was restored and the incision was then closed. What is the ICD-10-PCS procedure code for this surgery? ...
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Article Overview
This article reviews a second-stage upper-extremity vascular access surgery in a patient with end stage renal disease and focuses on ICD-10-PCS procedure coding. It is aimed at coders and revenue-cycle staff who work with dialysis access procedures, operative reports, and staged fistula surgeries. The article covers the operative scenario, the anatomy involved, and the coding question presented by the case.
Why This Topic Matters
Staged arteriovenous fistula procedures can be documented in ways that require careful interpretation of the operative note and procedure terminology. Understanding how the case is framed helps coding professionals identify the appropriate procedure category in ICD-10-PCS without relying on guesswork.
What You Will Learn
- How the staged fistula procedure is described in the operative narrative
- Which procedure coding system the article is focused on
- How documentation details from a dialysis access surgery are presented for coding review
- What kind of coding question is being asked about the case
Who Should Read This
- Inpatient coders
- Coding auditors
- Revenue cycle professionals
- Clinical documentation specialists
- Health information management staff
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