When performing two-staged vein transposition with either the upper arm basilic or cephalic vein for an AV fistula, what is the correct CPT code to report for each individual part of the staged procedure?
In the first stage of the procedure, the surgeon performs the vein transposition by creating an anastomosis between the cephalic vein and radial artery. During the second stage of the procedure, “superficialization” was performed, a procedure where the fistula is brought up closer to the skin.
Based on the documentation submitted in the operative report for Stage 1 of the procedure, report CPT code 36821, Arteriovenous anastomosis, open; direct, any site (e.g., Cimino type), and CPT code 36832, Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure), for the Stage 2 portion of the procedure.
When the procedure is performed in a single operative session as opposed to two stages, only CPT code 36818, Arteriovenous anastomosis, open; by upper arm cephalic vein transposition, or CPT code 36819, Arteriovenous anastomosis, open; by upper arm basilica vein transposition, would be reported.
Additionally, modifier 58, Staged or related procedure or service by the same physician during the postoperative period, would be appended to CPT code 36832 for the second stage of the procedure. Please note that for facility reporting, the postoperative period would be the same day.