Don’t Risk Denials: Expert Insight for Properly Coding AV Fistula Procedures

Navigating the complexities of interventional radiology coding in 2025 is more challenging than ever, with the threat of evolving guidelines, bundling restrictions, and payer scrutiny adding barriers of difficulty for coders. The percutaneous creation of an arteriovenous fistula (AVF), captured by CPT^® codes 36836 and 36837, is a critical procedure for hemodialysis patients, yet coding it correctly requires careful attention to included services and exclusionary rules. Even small missteps in documentation and code selection can have significant financial and compliance consequences. This month we down the nuances of AVF coding complete with a case example, equipping you with the knowledge needed to navigate these harsh realities and ensure accuracy in your coding practices for 2025 and beyond.

Comprehending Percutaneous Creation of Arteriovenous Fistula

When reporting hemodialysis access,  codes 36836 and 36837 cover the creation of a percutaneous arteriovenous (AV) fistula in the upper extremity. These codes detail a minimally invasive procedure where a peripheral artery and vein are accessed using image guidance—either through a single access site (36836) or two separate sites (36837). Once the vessels are approximated, energy (such as thermal) is applied to create the fistulous connection.

To ensure the fistula functions properly, maturation procedures may be necessary. This could involve techniques like angioplasty to enhance blood flow or coil embolization to redirect it. The bundling of codes continues to be a pitfall for many coders. There is a temptation to report certain elements separately but without checking properly, this could lead to incorrect code selection. When reporting 36836 or 36837, keep in mind that all aspects of the procedure—including vascular access, angiography, imaging guidance, and any necessary flow redirection—are bundled into these codes. That means additional services like balloon angioplasty or coil embolization performed during the same session cannot be reported separately.

36836 Percutaneous arteriovenous fistula creation, upper extremity, single access of both the peripheral artery and peripheral vein, including fistula maturation procedures (e.g., 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 (e.g., transluminal balloon angioplasty, coil embolization) when performed, including all vascular access, imaging guidance, and radiologic supervision and interpretation.

There are a series codes that cannot be reporting with either of the above codes. Do not report 36836 or 36837 in conjunction with 36005, 36140, 36215, 36216, 36217, 36218, 36245, 36246, 36247, 36837, 36901, 36902, 36903, 36904, 36905, 36906, 36907, 36908, 36909, 37236, 37238, 37241, 37242, 37246, 37248, 37252, 75710, 75716, 75820, 75822, 75894, 75898, 76937, 77001.

For arteriovenous fistula creation via an open approach, see 36800, 36810, 36815, 36818, 36819, 36820, 36821. When reporting percutaneous arteriovenous fistula creation in any location other than the upper extremity, use 37799.

Sample Case: Arteriovenous Grafts

Antibiotics were given. Time-out was called. The patient was identified. I prepped and draped the right groin and thigh. I punctured the venous limb of the thigh loop Gore-Tex graft antegrade and put a Nitrex wire through the graft under fluoro into the iliac vein on the right. I then put in a 4-French sheath and did a venogram. There was thrombus in the graft. I upsized to a 7-French sheath and then used the Cleaner mechanical apparatus and did mechanical thrombectomy of the venous outflow tract, which was very easy to do. I also sucked several times thrombus out of the 7-French sheath.

I then did a venogram, which showed a tight stenosis at the venous anastomosis of the Gore-Tex graft. I then put in a 0.018 wire and easily deployed a 7 x 50 Viabahn stent through this anastomotic stricture. I post-dilated with a #7 balloon. There was no waste. I then turned my attention to the arterial side of the limb and punctured it retrograde again out towards the distal curve of the graft. I put a Nitrex wire into the femoral artery. I infused a total of 8 mg of TPA in the graft, then used the Cleaner apparatus and cleaned the graft through the arterial inflow limb. After that was done, I had a palpable pulse in the AV graft despite having the two 7-French sheaths still in place.

CODE ASSIGNMENTS AND RATIONALE

36906 Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s); with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis circuit.

All of the work of this procedure is encompassed in code 36906. This code includes the diagnostic fistulagram/venogram, including punctures of both venous and arterial limbs, mechanical thrombectomy, and stent placement at the venous anastomosis. Do not report 36901 and/or 36903 separately, as these services are incorporated into 36906.

Your 2025 Coding Remains at Risk: These Are NOT All the Tips and Tricks Necessary for IR Success. With every dollar of reimbursement counting more than ever in the face of payment decline and complex changes, it’s imperative to make sure your CPTcoding is correct and compliant. Master more coding topics and break down the complexity with our 2025 Diagnostic and Therapeutic Dialysis Shunt Interventional Radiology Coding Webcast on March 12, 2025 at 11:00 am CT.