CPT code 36835 is used for a procedure that creates a connection between an artery and a vein, often for dialysis access.
CPT code 36835 is used to describe the surgical procedure of creating an arteriovenous (AV) fistula, which is an artery to vein shunt. This procedure involves connecting an artery directly to a vein, typically in the arm, to facilitate hemodialysis for patients with kidney failure. The AV fistula allows for efficient blood flow and access for dialysis treatment, providing a long-term solution for vascular access. This code is specifically used to document and bill for the creation of this type of vascular access in the healthcare revenue cycle.
For CPT code 36835, which involves an artery to vein shunt, the following modifiers may be applicable depending on the specific circumstances of the procedure:
1. Modifier 51 (Multiple Procedures): This modifier is used when multiple procedures are performed during the same surgical session. It indicates that the procedure is one of several performed on the same day.
2. Modifier 59 (Distinct Procedural Service): This modifier is applied when a procedure or service is distinct or independent from other services performed on the same day. It is used to indicate that the procedure is not part of a more comprehensive service.
3. Modifier 62 (Two Surgeons): If two surgeons are required to perform the procedure due to its complexity, this modifier indicates that each surgeon is performing a distinct part of the surgery.
4. Modifier 66 (Surgical Team): This modifier is used when a team of surgeons is necessary to perform the procedure due to its complexity.
5. Modifier 76 (Repeat Procedure by Same Physician): If the same physician needs to repeat the procedure on the same day, this modifier is used to indicate that it is a repeat procedure.
6. Modifier 77 (Repeat Procedure by Another Physician): This modifier is used when a different physician repeats the procedure on the same day.
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.
8. Modifier 79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period): This modifier is used when a procedure is performed during the postoperative period of another procedure, but it is unrelated to the original procedure.
9. Modifier 80 (Assistant Surgeon): If an assistant surgeon is required for the procedure, this modifier indicates their involvement.
10. Modifier 82 (Assistant Surgeon [when qualified resident surgeon not available]): This modifier is used when an assistant surgeon is necessary, and a qualified resident is not available.
11. Modifier AS (Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery): This modifier is used when a non-physician practitioner assists in the surgery.
The use of these modifiers should be carefully considered based on the specific details of the procedure and the circumstances under which it was performed. Proper documentation is essential to support the use of any modifier.
The CPT code 36835 is subject to reimbursement by Medicare, but its coverage and payment are determined by several factors. The Medicare Physician Fee Schedule (MPFS) is a critical resource for understanding whether a specific CPT code, such as 36835, is reimbursed and at what rate. The MPFS outlines the payment rates for services provided to Medicare beneficiaries, and it is updated annually to reflect changes in policy and practice.
However, the reimbursement for CPT code 36835 can also be influenced by the local policies of the Medicare Administrative Contractors (MACs). MACs are private organizations that contract with Medicare to process claims and determine coverage at a regional level. They have the authority to make decisions on the medical necessity and appropriateness of services, which can affect whether a particular service is reimbursed.
Therefore, while CPT code 36835 is listed in the MPFS, healthcare providers should verify with their specific MAC to ensure that the service is covered and reimbursed in their region. This dual-layered approach ensures that providers are accurately informed about the reimbursement potential for the services they offer to Medicare beneficiaries.
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