CPT code 36819 is for a surgical procedure that creates a connection between the basilic vein and an artery in the upper arm for dialysis access.
CPT code 36819 is used to describe the surgical procedure of creating an arteriovenous (AV) fistula in the upper arm, specifically involving the basilic vein. This procedure is typically performed to facilitate hemodialysis in patients with chronic kidney disease. During the surgery, the basilic vein is connected to an artery, usually the brachial artery, to create a durable access point that allows for efficient blood flow during dialysis sessions. This type of AV fistula is often chosen for its long-term viability and lower complication rates compared to other access methods.
For CPT code 36819, which involves procedures related to arteriovenous (AV) fistula creation in the upper arm, the following modifiers may be applicable:
1. Modifier 22 - Increased Procedural Services: This modifier is used when the work required to perform the procedure is substantially greater than typically required. This could be due to complications or other factors that increase the complexity of the procedure.
2. Modifier 52 - Reduced Services: If the procedure is partially reduced or eliminated at the physician's discretion, this modifier can be applied to indicate that the service provided was less than what is typically required.
3. Modifier 53 - Discontinued Procedure: This is used when a procedure is started but discontinued due to extenuating circumstances or those that threaten the well-being of the patient.
4. Modifier 59 - Distinct Procedural Service: This modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. It is often used to bypass National Correct Coding Initiative (NCCI) edits.
5. Modifier 76 - Repeat Procedure by Same Physician: If the same procedure is repeated by the same physician, this modifier is used to indicate that the repeat procedure was necessary.
6. Modifier 77 - Repeat Procedure by Another Physician: Similar to Modifier 76, but used when the repeat procedure is performed by a different physician.
7. Modifier 78 - Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period: This modifier is used when a patient returns to the operating room for a related procedure during the postoperative period of the initial surgery.
8. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: This is used when a procedure is performed during the postoperative period of another procedure, but is unrelated to the original procedure.
9. Modifier 80 - Assistant Surgeon: This modifier is used when an assistant surgeon is required for the procedure.
10. Modifier 81 - Minimum Assistant Surgeon: Used when an assistant surgeon is required for a minimal portion of the procedure.
11. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): This is used when an assistant surgeon is necessary because a qualified resident surgeon is not available.
12. Modifier 99 - Multiple Modifiers: When more than four modifiers are necessary to describe the service, this modifier is used to indicate that multiple modifiers apply.
These modifiers help provide additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement. Always verify with the latest coding guidelines and payer-specific requirements, as these can change over time.
The CPT code 36819 is subject to reimbursement by Medicare, but its coverage and payment are determined by several factors. The Medicare Physician Fee Schedule (MPFS) plays a crucial role in establishing the reimbursement rates for services covered under Medicare Part B. The MPFS outlines the payment amounts for each CPT code, including 36819, based on the relative value units (RVUs) assigned to the service, geographic location, and other factors.
However, it's important to note that the final determination of whether CPT code 36819 is reimbursed can also depend on the local policies set by the Medicare Administrative Contractor (MAC) in your region. MACs are responsible for processing Medicare claims and have the authority to establish local coverage determinations (LCDs) that may affect the reimbursement of specific services. Therefore, healthcare providers should consult the MPFS for the national payment rate and check with their local MAC for any specific coverage guidelines or requirements related to CPT code 36819.
Discover the power of MD Clarity's RevFind software to ensure you're receiving the full reimbursement you deserve. With the ability to read your contracts and detect underpayments down to the CPT code level, including specific codes like 36819, RevFind provides unparalleled insight into individual payer discrepancies. Schedule a demo today to see how RevFind can enhance your revenue cycle management and optimize your financial outcomes.
Get paid in full by bringing clarity to your revenue cycle
Subscribe to the
Healthcare Clarified newsletter
Get the latest insights on RCM and healthcare policy in your inbox
