How To Use CPT Code 36831

CPT 36831 describes the surgical procedure of thrombectomy for an arteriovenous fistula without revision, specifically for autogenous or nonautogenous dialysis grafts. This article will provide an overview of CPT 36831, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 36831?

CPT 36831 is a code used to describe a surgical procedure known as thrombectomy. This procedure involves the removal of a blood clot from an arteriovenous fistula, which is a connection between an artery and a vein. The thrombectomy is performed on autogenous or nonautogenous dialysis grafts, which are commonly used for dialysis purposes. It is important to note that this procedure does not involve any revision of the fistula itself.

2. Official Description

The official description of CPT code 36831 is: ‘Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous dialysis graft (separate procedure).’ This code specifically refers to the surgical removal of a blood clot from an arteriovenous fistula without any revision of the fistula itself.

3. Procedure

1. During the procedure, the healthcare provider begins by making an incision over the arteriovenous fistula.
2. They then carefully dissect the fistula free.
3. Next, a clamp is placed over the artery and vein to temporarily stop the blood flow.
4. The provider clears the area around the vein or artery and makes an incision at the location of the clot.
5. The blood clot is then carefully removed from the graft.
6. The graft is flushed to remove any loose debris or air.
7. The clamp is removed to restore blood flow through the vessel.
8. Finally, the graft is sutured and the wound is closed by suturing the soft tissue layers.

4. Qualifying circumstances

CPT 36831 is typically performed on patients who have an arteriovenous fistula that requires thrombectomy. This procedure is specifically intended for autogenous or nonautogenous dialysis grafts. It is important to note that this code is used when the provider does not perform any revision of the fistula during the thrombectomy procedure.

5. When to use CPT code 36831

CPT code 36831 should be used when a healthcare provider performs an open thrombectomy procedure on an arteriovenous fistula without any revision of the fistula itself. It is important to ensure that the procedure is specifically performed on autogenous or nonautogenous dialysis grafts. If the provider performs a revision of the fistula along with the thrombectomy, a different CPT code should be used.

6. Documentation requirements

To support a claim for CPT 36831, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for thrombectomy
• Specific details about the arteriovenous fistula and the type of graft used
• Date of the procedure
• Details of the procedure, including the incision, dissection, use of clamps, removal of the clot, flushing of the graft, and closure of the wound
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 36831, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The provider should not report CPT 36831 if the procedure involves revision of the arteriovenous fistula or if it is performed in conjunction with a related procedure through the same skin incision. If the procedure is performed with an unrelated procedure, modifier 59 may need to be appended to CPT 36831 to indicate that it is a distinct procedural service.

8. Historical information

CPT 36831 was added to the Current Procedural Terminology system on January 1, 1999. There have been no updates or changes to the code since its addition.

9. Examples

1. A surgeon performs a thrombectomy on an autogenous dialysis graft for a patient with a clot in their arteriovenous fistula.
2. A vascular specialist removes a blood clot from a nonautogenous dialysis graft during a thrombectomy procedure.
3. A healthcare provider performs an open thrombectomy on an arteriovenous fistula without any revision for a patient with a clot in their autogenous dialysis graft.
4. A surgeon performs a thrombectomy on a nonautogenous dialysis graft for a patient with a clot in their arteriovenous fistula.
5. A vascular specialist removes a blood clot from an autogenous dialysis graft during an open thrombectomy procedure.
6. A healthcare provider performs a thrombectomy on an arteriovenous fistula without any revision for a patient with a clot in their nonautogenous dialysis graft.
7. A surgeon performs a thrombectomy on an autogenous dialysis graft for a patient with a clot in their arteriovenous fistula.
8. A vascular specialist removes a blood clot from a nonautogenous dialysis graft during a thrombectomy procedure.
9. A healthcare provider performs an open thrombectomy on an arteriovenous fistula without any revision for a patient with a clot in their autogenous dialysis graft.