AV Fistulas ICD-10 Coding Guide (FY2026)

Table of Contents

AV Fistulas — Clinical Documentation Guide featured image

Code year: FY2026 (Oct 1 2025 – Sep 30 2026) Audience: Certified Coders, Auditors and Clinical Documentation Specialists Access: CCO Members Last updated: April 2026

This Clinical Documentation Guide (CDG) provides AAPC/AHIMA-credentialed coders and CDI specialists with comprehensive coding, clinical, and documentation guidance for arteriovenous (AV) fistulas and grafts used for hemodialysis vascular access. Content reflects FY2026 ICD-10-CM guidelines (effective October 1, 2025 – September 30, 2026) and incorporates current CPT 2026 procedure coding. For related end-stage renal disease (ESRD) and chronic kidney disease coding, see the companion Renal Failure / CKD / Dialysis CDG. Use this guide to ensure accurate diagnosis assignment, appropriate CDI query triggers, and defensible documentation for AV fistula/graft creation, maintenance, and complication encounters across all care settings.

1. Definition

An arteriovenous (AV) fistula is a surgically created direct anastomosis between an artery and a vein, bypassing the capillary bed, to provide reliable, high-flow vascular access for hemodialysis. The most common configuration is a wrist (radiocephalic) or elbow (brachiocephalic or brachiobasilic) fistula. Following creation, a maturation period of typically 6–12 weeks is required before the fistula is suitable for cannulation, as described by KDOQI Vascular Access Guidelines.

An arteriovenous graft (AVG) is a vascular access device created by interposing a prosthetic or biological conduit (most commonly expanded polytetrafluoroethylene, ePTFE) between an artery and a vein when the patient’s native vessels are unsuitable for direct fistula creation. Grafts may be used earlier (as soon as 2 weeks post-creation) but carry higher rates of thrombosis and infection compared to native fistulas, per NIDDK hemodialysis access guidance.

Scope of this guide: Dialysis-dependent AV fistulas and grafts — creation, maintenance, complications, and interventional management. Separate classifications apply to congenital AV malformations (Q27.33, Q27.34), traumatic/acquired AV fistulas (I77.0), and pulmonary AV fistulas (Q25.72, I28.0), each addressed in the code set section below.

Epidemiology & Clinical Significance

Approximately 560,000 patients in the United States receive maintenance hemodialysis for ESRD. Vascular access complications are a leading cause of hospitalization among dialysis patients, accounting for roughly 25% of all dialysis-related admissions. Native AV fistulas remain the preferred access type per the Fistula First Breakthrough Initiative due to lower infection risk, longer patency, and lower overall cost. Accurate ICD-10-CM and CPT coding of access creation, revision, and complications directly impacts DRG assignment, HCC risk scores, and quality metrics under CMS ESRD Quality Incentive Program (QIP).

2. Alternative Terminology

The following table lists formal and colloquial terminology coders and CDI specialists may encounter in documentation:

Formal / Clinical Term	Colloquial / Lay / Alternate Names
Arteriovenous fistula (AVF)	“Fistula,” “AV fistula,” “dialysis fistula,” “access,” “the bump”
Arteriovenous graft (AVG)	“Graft,” “AV graft,” “dialysis graft,” “loop graft,” “bridge graft,” “synthetic access”
Radiocephalic fistula	Brescia-Cimino fistula, wrist fistula, forearm fistula, RC fistula
Brachiocephalic fistula	Elbow fistula, upper arm fistula, antecubital fistula, BC fistula
Brachiobasilic fistula with transposition	Basilic vein transposition, BBT, upper arm basilic fistula
Maturation failure / non-maturing fistula	“Failed fistula,” “immature fistula,” “doesn’t develop,” “fistula not ready”
Steal syndrome	Dialysis access steal, ischemic steal, distal ischemia from AV access, DASS (dialysis access steal syndrome)
Thrombosis of AVF/AVG	“Clotted fistula,” “clotted graft,” “lost access,” “thrombosed access”
Pseudoaneurysm	“False aneurysm,” “pulsatile mass,” “needle-site aneurysm,” “hematoma with flow”
True aneurysmal dilation	“Aneurysm,” “ballooning,” “focal dilation,” “bulge in fistula”
Venous stenosis / outflow stenosis	“Narrowing,” “cephalic arch stenosis,” “juxta-anastomotic stenosis,” “outflow problem”
Central venous stenosis / occlusion	CVO, central stenosis, subclavian stenosis, SVC syndrome (from prior catheters)
Endovascular AVF (endoAVF)	Ellipsys fistula, WavelinQ fistula, percutaneous fistula, minimally invasive AVF
Tunneled dialysis catheter (TDC)	Permacath, Hickman dialysis catheter, TDC, long-term catheter
Hemodialysis vascular access	Dialysis access, HD access, blood access, vascular access site

3. Signs & Symptoms

Clinical presentation varies by the phase of fistula/graft management (creation, maturation, maintenance, or complication). Coders should ensure documentation clearly captures the clinical status precipitating the encounter.

Functioning Access (Normal Findings)

Palpable thrill (continuous vibration over anastomosis)
Audible bruit on auscultation
Adequate flow rates (>600 mL/min for fistulas, >800 mL/min for grafts)
Visible engorgement of superficial veins along fistula segment

Maturation Failure

Fistula fails to dilate sufficiently 6–8 weeks post-creation
Inadequate flow (Qa <500 mL/min)
Failure of vein wall thickening (“arterialization”)
Vessel diameter <6 mm on ultrasound

Thrombosis (T82.858A / T82.868A)

Absent thrill and bruit — acute loss of access
Pain, swelling, or erythema over access site
Inability to achieve adequate dialysis flow rates
Collapsed or pulseless fistula segment

Steal Syndrome (Dialysis Access Steal Syndrome)

Hand pain, pallor, paresthesias, or coolness distal to fistula
Symptoms worsen during dialysis
Digital ischemia or gangrene in severe cases
Reduced digital pressure index (<0.6)

Infection (T82.7xxA)

Erythema, warmth, swelling, purulent discharge at access site
Fever, bacteremia, sepsis — especially with Staphylococcus aureus
Graft infections typically more severe and require explantation

Aneurysm / Pseudoaneurysm

Pulsatile mass or visible bulge over fistula
Thinning of overlying skin; skin discoloration
Risk of rupture if skin is compromised
True aneurysm: all three vessel wall layers involved
Pseudoaneurysm (I72.x): contained hematoma communicating with vessel lumen — often needle-track related

Stenosis (Outflow / Central)

Decreased blood flow rates during dialysis (<300 mL/min drop)
Prolonged bleeding after needle removal
Elevated venous pressures during dialysis
Arm edema (central venous stenosis — I87.1)
Facial/neck swelling (SVC syndrome from central venous occlusion)

💬 CDI Query Trigger

When documentation notes “clotted fistula,” “lost access,” “fistula not working,” or “dialysis access problem,” query the physician to specify: (a) thrombosis, (b) stenosis/outflow obstruction, (c) infection/inflammation, (d) steal syndrome, or (e) maturation failure. Each has a distinct ICD-10-CM code with different HCC and reimbursement implications.

4. Differential Diagnosis

Condition	Key Distinguishing Features	ICD-10-CM Code
AVF/AVG thrombosis	Acute loss of thrill/bruit; confirmed by duplex ultrasound or fistulogram; no blood flow on imaging	T82.858A / T82.868A
AVF/AVG stenosis (outflow)	Elevated venous pressures; reduced Qa; intact thrill; confirmed by angiography or duplex	T82.858A (with stenosis documentation) / I87.1 (central)
AVF/AVG infection	Local signs of infection; bacteremia; WBC elevation; positive cultures; may follow catheter placement	T82.7xxA
Steal syndrome	Hand ischemia distal to access; worsens during dialysis; digital pressure index <0.6; improved by fistula compression	I77.1 (stricture/arterial spasm component)
True aneurysm of AVF	Pulsatile mass; all vessel wall layers intact; duplex shows laminar flow; gradual dilation over time	I77.1 (aneurysmal dilation) / T82.858A
Pseudoaneurysm of AVF	Focal pulsatile mass at needle-cannulation site; duplex shows yin-yang swirling flow; no true vessel wall	I72.x (by site — e.g., I72.1 aneurysm of upper extremity artery)
Central venous stenosis/occlusion	Ipsilateral arm edema; history of prior central venous catheter; confirmed by venogram; I87.1	I87.1 compression of vein
Hematoma at access site	Non-pulsatile swelling post-cannulation; no flow on duplex; resolves with conservative management	T82.838A (hemorrhage — other vascular device) or local wound complication code
Seroma / fluid collection around graft	Non-infected fluid around prosthetic graft; ultrasound-guided aspiration; may indicate early graft degradation	T82.838A or T82.498A (other mechanical complication)
Non-maturing fistula	Post-surgical; fistula fails to arterialized by 6–8 weeks; duplex confirms inadequate diameter/flow; may require revision	T82.41xA (breakdown of AVF — initial encounter) or T82.498A
Congenital AV malformation	Present since birth or childhood; imaging shows abnormal arteriovenous communication without prior surgery; renal vessel involvement	Q27.33 / Q27.34
Traumatic/acquired AVF (non-dialysis)	History of penetrating trauma or iatrogenic injury; no prior surgical fistula creation; continuous bruit at site of trauma	I77.0 acquired AVF

5. Clinical Indicators for Coders/CDI

The following indicators from the medical record should be captured or queried to ensure complete, accurate coding of AV fistula/graft encounters:

Clinical Indicator	Documentation to Look For	Coding Impact
Type of vascular access	“AVF,” “AVG,” “catheter,” “fistula,” “graft,” “Permacath,” “tunneled catheter”	Determines CPT selection (36818–36830 vs. catheter codes); drives ICD-10 specificity
Location / configuration	“Radiocephalic,” “brachiocephalic,” “brachiobasilic,” “upper arm,” “forearm”	Required for CPT code selection (36818 vs. 36819 vs. 36820 vs. 36821)
Creation vs. revision vs. intervention	Operative note: “creation,” “revision,” “thrombectomy,” “angioplasty,” “stent”	CPT codes differ significantly; unbundling risk if revision + thrombectomy coded separately when joint procedure
ESRD / dialysis dependence	Z99.2, N18.6; dialysis flow sheets; ESRD designation in problem list	HCC 139 (Z99.2) ~0.436 RAF; annual capture required; ESRD QIP measures
Nature of complication	“Thrombosis,” “stenosis,” “infection,” “steal,” “aneurysm,” “bleeding,” “hematoma”	T82.x series — different complication codes carry different HCC and audit risk implications
Initial vs. subsequent encounter	7th character “A” (initial), “D” (subsequent), “S” (sequela) — determined by phase of care, not number of visits	7th character determines T82.x code; initial encounter for active treatment; subsequent for healing/follow-up
Maturation status	“Fistula maturing,” “not yet usable,” “first use,” “immature,” “failed to mature”	Affects CPT and ICD-10 selection; maturation failure may require T82.41xA breakdown code
Adequacy testing	“Kt/V,” “URR,” “adequacy testing,” “dialysis adequacy”	Z49.31 encounter for adequacy testing for hemodialysis; distinct from treatment encounter
Autogenous vs. synthetic graft	“ePTFE,” “synthetic graft,” “autogenous vein,” “vein graft”	CPT 36825 (autogenous) vs. 36830 (non-autogenous); affects reimbursement
Endovascular vs. open creation	“Ellipsys,” “WavelinQ,” “percutaneous AV fistula,” “endovascular creation”	CPT 36836–36837 (endovascular AVF) vs. 36818–36821 (open)

📝 Coder Note

The 7th character for T82.x complication codes is driven by the phase of care, not how many times the patient has been seen. “A” (initial encounter) applies when the patient is receiving active treatment for the complication. “D” (subsequent encounter) applies during the healing/monitoring phase. Most acute presentations of AVF complications use “A.” Document provider language carefully — “follow-up for clotted fistula” that still requires active treatment should still use “A.” Per FY2026 ICD-10-CM Official Guidelines, Section I.C.19.

6. Anatomy & Pathophysiology

Relevant Anatomy

Upper extremity vascular access uses the following vessels, as described in StatPearls: Hemodialysis Access:

Radial artery / cephalic vein (wrist) → Radiocephalic fistula (Brescia-Cimino) — preferred first option
Brachial artery / cephalic vein (antecubital) → Brachiocephalic fistula — second-line option
Brachial artery / basilic vein with transposition → Brachiobasilic fistula — requires two-stage procedure; basilic vein superficialized for cannulation
Forearm veins / radial or ulnar artery → Forearm transposition (36820)
Prosthetic graft loops (ePTFE) → Usually brachial artery to antecubital vein or axillary vein

Hemodynamic Changes After AVF Creation

When a surgical anastomosis is created between the high-pressure arterial system and the low-pressure venous system, flow is redirected through the fistula. The resulting high-velocity, turbulent flow causes:

Vein arterialization: The vein wall thickens and dilates due to increased wall shear stress, a process required for successful maturation
Increased cardiac output: Significant AVFs (especially upper arm) can increase cardiac output by 1–2 L/min, relevant in patients with pre-existing cardiac disease
Distal ischemia risk: Arterial blood is “stolen” away from the distal extremity, particularly with high-flow fistulas in elderly or diabetic patients with pre-existing peripheral arterial disease

Pathophysiology of Common Complications

Thrombosis: Most commonly due to outflow stenosis causing progressive flow reduction, hypercoagulable states, hypotension during dialysis, or external compression. Accounts for >80% of access loss events per KDOQI Guidelines.
Stenosis: Intimal hyperplasia (smooth muscle cell proliferation) at the venous anastomosis is the hallmark lesion of both native fistula and graft dysfunction. Cephalic arch stenosis is particularly common in brachiocephalic fistulas.
Infection: Bacteremia from AVG infection is predominantly Staphylococcus aureus (including MRSA); native fistula infections are less frequent. Graft infections often require partial or complete graft excision.
Steal syndrome: Pathologic reversal of distal arterial flow during dialysis; more common with high-flow brachial artery-based access; managed with DRIL procedure (distal revascularization-interval ligation), PAI (proximalization of arterial inflow), or banding.

7. Medication Impact / Treatment

Anemia Management (ESRD-Related)

Patients with ESRD on hemodialysis require ongoing anemia management. The following agents are relevant to coding and HCPCS billing:

Erythropoiesis-stimulating agents (ESAs): Epoetin alfa (Q4081 — 100 units for ESRD on dialysis), darbepoetin alfa (J0882), methoxy polyethylene glycol-epoetin beta (J0887). ESA dosing and administration is closely tied to hemoglobin targets per CMS ESRD QIP quality measures.
IV Iron supplementation: Ferric carboxymaltose (J1439), ferric pyrophosphate citrate (J1443–J1444) — commonly used in dialysis patients for iron-deficiency anemia associated with ESRD.

Anticoagulation / Antiplatelet Therapy

Antiplatelet agents (aspirin, clopidogrel) may be prescribed to maintain fistula patency, particularly for grafts or recurrent thrombosis
Warfarin or direct oral anticoagulants (DOACs) used for hypercoagulable states or concurrent atrial fibrillation
Heparin administered during dialysis sessions for circuit anticoagulation — documented on dialysis flow sheets

Thrombolytic Therapy

Alteplase (tPA) or other thrombolytics may be administered pharmacomechanically during catheter-directed thrombolysis for AVF/AVG thrombosis (captured under CPT 36904–36906 pharmacomechanical thrombolysis)

Antimicrobial Therapy

IV vancomycin or daptomycin for MRSA/gram-positive bacteremia from infected graft
Antibiotic-impregnated grafts or local antibiotic depot therapy for graft salvage in selected cases
Prolonged IV antibiotics required for graft infection — impacts admission length and DRG assignment

⚠️ Common Pitfall

Do not use Z45.82 (encounter for adjustment/management of infusion pump) for AVF/AVG maintenance encounters — this code is specific to implanted infusion pumps (e.g., intrathecal drug pumps), not dialysis access. Similarly, Z95.5 (presence of coronary angioplasty implant) is not applicable to AVFs or AVGs — it is specific to coronary stents. These are common miscoding errors flagged in CMS ICD-10-CM Guidelines audits.

Preview ends here. The full guide continues with FY2026 ICD-10-CM code sets, CPT surgical coding, MS-DRG mapping, reimbursement guidance, CDI query templates, and an audit checklist — all available to CCO Members.

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8. ICD-10-CM Guidelines (FY2026)

General Principles for AV Fistula/Graft Coding

Per FY2026 ICD-10-CM Official Guidelines, Section I.C.19 (Injury, Poisoning and Certain Other Consequences of External Causes):

Complications of devices, implants, and grafts are coded from categories T82.x (cardiac and vascular prosthetic devices, implants, and grafts). Dialysis access devices (AVF and AVG) fall under this category.
7th character “A” (initial encounter) is used while the patient is receiving active treatment for the complication — including surgeries, ED visits, and interventional procedures to address the complication.
7th character “D” (subsequent encounter) is used for encounters after active treatment has concluded, during the recovery/monitoring phase.
7th character “S” (sequela) is used for complications that are sequelae of the device complication.
When a complication of a vascular device results in a separate condition (e.g., septicemia from graft infection), code both the complication (T82.7xxA) and the resulting condition (e.g., A41.01 Sepsis due to MRSA).

Sequencing Rules

For encounters specifically for a complication of an AVF/AVG, the T82.x complication code is sequenced as the principal diagnosis (inpatient) or first-listed diagnosis (outpatient).
Z99.2 (Dependence on renal dialysis) and N18.6 (ESRD) should be coded as additional diagnoses whenever the patient is dialysis-dependent, regardless of the primary reason for the encounter. These are high-value HCC codes (HCC 139) that require annual documentation.
For elective AVF/AVG creation in a dialysis patient, the reason for access creation (e.g., Z49.01 encounter for fitting and adjustment of extracorporeal dialysis catheter, or N18.6 ESRD) drives the encounter, with procedure codes capturing the creation.
When both AVF creation and revision/thrombectomy are performed at the same session, refer to CPT bundling rules — many interventional codes are bundled within the dialysis circuit code families (36901–36909).

Dialysis Status vs. ESRD — Dual Coding

Per ICD-10-CM Official Guidelines: Both N18.6 (ESRD) and Z99.2 (dependence on renal dialysis) should be assigned concurrently when the patient has ESRD on dialysis. The Z99.2 code specifically captures the HCC for dialysis status. Do not use Z99.2 alone without N18.6 for ESRD patients — both codes are needed for complete HCC capture. See the companion Renal Failure / CKD / Dialysis CDG for detailed ESRD and CKD staging guidelines.

Congenital vs. Acquired vs. Dialysis AVF Distinction

Documentation must clarify the etiology of any arteriovenous communication:

Dialysis-created AVF/AVG → T82.x series for complications; creation captured by CPT 36818–36830 or 36836–36837
Congenital AV malformation → Q27.33 (renal vessel) or Q27.34 (other specified congenital AV malformation); these are NOT T82 complications
Acquired (traumatic/iatrogenic) AVF → I77.0 (acquired arteriovenous fistula) — not a dialysis access complication code
Pulmonary AVF → Q25.72 (congenital) or I28.0 (acquired); separate from peripheral dialysis access entirely

🛡️ Audit Alert

Auditors frequently flag the improper use of I77.0 (acquired AVF) for dialysis fistulas. I77.0 is reserved for pathological or traumatic arteriovenous fistulas — not surgically created dialysis access. Dialysis AVF/AVG complications belong to T82.x categories. Using I77.0 for a dialysis access complication will result in claim denial or audit findings per CMS ICD-10-CM Guidelines.

9. ICD-10-CM Code Set (FY2026)

ICD-10-CM Code	Description	Notes / Common Use
Dialysis Status & ESRD (code together)
N18.6	End-stage renal disease (ESRD)	Always code with Z99.2 for dialysis patients; HCC 139 per CMS HCC v28
Z99.2	Dependence on renal dialysis / Long-term (current) dependence on renal dialysis	Required additional diagnosis at every encounter for dialysis patients; HCC 139 (~0.436 RAF); captures dialysis status for HCC purposes
Z49.01	Encounter for fitting and adjustment of extracorporeal dialysis catheter	Use for catheter adjustment encounters; not for AVF/AVG maintenance per se
Z49.02	Encounter for fitting and adjustment of peritoneal dialysis catheter	Peritoneal dialysis catheter — not hemodialysis AVF/AVG
Z49.31	Encounter for adequacy testing for hemodialysis	Kt/V testing, URR measurements, dialysis adequacy assessment encounters
Z49.32	Encounter for adequacy testing for peritoneal dialysis	PD adequacy — not hemodialysis
AVF/AVG Complications — Mechanical (T82 series)
T82.41xA	Breakdown (mechanical) of vascular dialysis catheter, initial encounter	Use for structural failure/breakdown of AVF or AVG requiring active treatment; “A” for initial encounter
T82.43xA	Leakage of vascular dialysis catheter, initial encounter	Leakage at anastomosis or along graft — initial active treatment encounter
T82.498A	Other mechanical complication of other cardiac and vascular devices, implants and grafts, initial encounter	Catch-all for mechanical complications not specifically classified elsewhere (e.g., kinked graft, seroma, non-specific mechanical failure)
T82.7xxA	Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter	AVF/AVG infection; code also the specific infecting organism (e.g., B95.61 MRSA); one of highest HCC-impacting complication codes (HCC 265)
T82.818A	Embolism due to vascular prosthetic devices, implants and grafts, initial encounter	Embolic complication from AVF/AVG thrombus; distinguish from peripheral arterial embolism (I74.x)
T82.838A	Hemorrhage due to vascular prosthetic devices, implants and grafts, initial encounter	Bleeding from AVF/AVG site; post-cannulation hemorrhage requiring active treatment
T82.848A	Pain due to vascular prosthetic devices, implants and grafts, initial encounter	Documented pain attributable to AVF/AVG; distinguish from steal syndrome ischemic pain (I77.1)
T82.858A	Stenosis of vascular prosthetic devices, implants and grafts, initial encounter	Most commonly used for AVF/AVG thrombosis AND stenosis in practice; thrombosis of AVF/AVG is most frequently captured under this code; confirm with provider documentation
T82.868A	Thrombosis of other cardiac and vascular grafts and implants, initial encounter	Specific thrombosis code for grafts and implants; use T82.868A for documented AVF/AVG thrombosis when documentation explicitly states “thrombosis”; HCC 265 eligible
T82.898A	Other specified complication of vascular prosthetic devices, implants and grafts, initial encounter	Use for complications not captured in specific T82 codes (e.g., fistula fibrosis, scarring, maturation failure not otherwise specified)
Vascular Complications (Non-Device Codes)
I77.0	Acquired arteriovenous fistula	NOT for dialysis access — reserved for traumatic, iatrogenic (post-procedure), or pathological AVF not created for dialysis; common in post-catheterization femoral artery AVF
I77.1	Stricture of artery / aneurysmal dilation	Steal syndrome (arterial spasm/stricture distal to AVF); true aneurysmal dilation of AVF; supplement with specific complication code when applicable
I72.1	Aneurysm of artery of upper extremity	Pseudoaneurysm of AVF at brachial or radial artery territory; use I72.x by specific site
I72.8	Aneurysm of other specified arteries	Pseudoaneurysm at other AVF sites not captured by more specific I72 codes
I74.2	Embolism and thrombosis of arteries of upper extremities	Peripheral arterial thromboembolism distal to AVF (steal-related ischemia with documented thrombus)
I74.3	Embolism and thrombosis of arteries of lower extremities	Lower extremity AVF complications (femoral AVF)
I87.1	Compression of vein	Central venous stenosis from prior catheter placement; ipsilateral arm edema; subclavian/SVC stenosis
Congenital & Other AV Communications
Q27.33	Arteriovenous malformation of renal vessel	Congenital — not dialysis-related; renal AVM
Q27.34	Arteriovenous malformation of digestive system vessel	Congenital GI AVM — not dialysis-related
Q25.72	Congenital pulmonary arteriovenous fistula	Pulmonary AVM — genetic/HHT-related; entirely separate from peripheral dialysis access
I28.0	Arteriovenous fistula of pulmonary vessels (acquired)	Acquired pulmonary AV fistula — separate from dialysis access
ESRD & CKD (for cross-reference — see Renal/CKD CDG)
N18.6	End-stage renal disease	Code with Z99.2 at every dialysis encounter; see Renal Failure/CKD/Dialysis CDG for full staging guidance
N18.5	Chronic kidney disease, stage 5 (CKD5 — pre-dialysis)	HCC 138 (~0.236 RAF) — use when ESRD not yet established (GFR <15 without dialysis)

📝 Coder Note — T82.858A vs. T82.868A for AVF/AVG Thrombosis

In practice, T82.858A (stenosis of vascular prosthetic devices) is commonly applied to both stenosis AND thrombosis of AVF/AVGs in many facility coding workflows. However, when the physician’s documentation explicitly states “thrombosis” of an AVF or AVG, T82.868A (thrombosis of other cardiac and vascular grafts and implants) is the more precise code. Query the provider to distinguish thrombosis from stenosis when documentation is ambiguous — both carry HCC 265 implications but differ in specificity. Refer to AHA Coding Clinic guidance for the most current direction on T82 subcategory selection for dialysis access.

10. Indexing

Use the following FY2026 ICD-10-CM Index to Diseases and Injuries pathways:

Index Entry	Subterms	Code Result
Complication(s) → vascular device → graft or implant NEC	→ thrombosis → T82.868A; → stenosis → T82.858A; → infection → T82.7xxA; → hemorrhage → T82.838A; → embolism → T82.818A; → leakage → T82.43xA; → breakdown → T82.41xA	T82.x series
Fistula → arteriovenous → acquired → traumatic	→ I77.0	I77.0
Fistula → arteriovenous → congenital → NEC	→ Q27.30 or Q27.33 (renal)	Q27.3x
Fistula → arteriovenous → pulmonary (acquired)	→ I28.0	I28.0
Dependence → dialysis (renal)	→ Z99.2	Z99.2
Status (post) → dialysis (hemodialysis) (peritoneal)	→ Z99.2	Z99.2
Disease → kidney → end-stage (failure)	→ N18.6	N18.6
Steal syndrome → dialysis access	→ index under “Syndrome, steal” → I77.1	I77.1
Aneurysm → false (pseudoaneurysm) → upper extremity	→ I72.1	I72.1
Stenosis → vein → central (venous)	→ I87.1	I87.1
Encounter → dialysis → hemodialysis → adequacy testing	→ Z49.31	Z49.31

11. CPT (2026)

CPT codes for AV fistula and graft procedures are drawn from the AMA CPT 2026 codebook. The dialysis circuit interventional codes (36901–36909) underwent a major restructuring effective 2020 and represent the current standard for endovascular access procedures.

CPT Code	Description	Global Period	Notes
AVF/AVG Creation — Open
36818	Arteriovenous anastomosis, open; by upper arm cephalic vein transposition	90 days	Upper arm brachiocephalic with cephalic vein transposition; requires mobilization and transposition of cephalic vein
36819	Arteriovenous anastomosis, open; by upper arm basilic vein transposition	90 days	Brachiobasilic fistula — basilic vein transposed to superficial position; may be one or two-stage procedure
36820	Arteriovenous anastomosis, open; by forearm vein transposition	90 days	Forearm cephalic or basilic vein transposition to forearm artery
36821	Arteriovenous anastomosis, open; direct, any site (e.g., Brescia-Cimino type)	90 days	Direct anastomosis without transposition — most commonly radiocephalic (wrist fistula); any site with direct anastomosis
36825	Creation of arteriovenous fistula by other than direct arteriovenous anastomosis; autogenous graft	90 days	AVG using patient’s own vein (autologous); saphenous vein graft; requires vein harvesting
36830	Creation of arteriovenous fistula by other than direct arteriovenous anastomosis; nonautogenous graft (e.g., synthetic, modified, or bovine graft)	90 days	Synthetic AVG (ePTFE most common); bovine carotid graft; “bridge graft” between artery and vein
AVF Creation — Endovascular (New 2020+)
36836	Percutaneous arteriovenous fistula creation, upper extremity, single access	90 days	Endovascular AVF using catheter-based devices (Ellipsys, WavelinQ); single access point; minimally invasive; requires pre-procedure imaging
36837	Percutaneous arteriovenous fistula creation, upper extremity, with dual access	90 days	Endovascular AVF with two access points (arterial and venous); WavelinQ 4F system typically; report 36837 when dual access used
AVF/AVG Revision and Thrombectomy — Open
36831	Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous graft (separate procedure)	90 days	Open surgical clot removal without fistula revision; “separate procedure” designation — do not report with 36833
36832	Revision, open, arteriovenous fistula or graft without thrombectomy	90 days	Surgical revision (e.g., angioplasty/patch, anastomosis revision) without concurrent thrombectomy; no clot present
36833	Revision, open, arteriovenous fistula or graft with thrombectomy, autogenous or nonautogenous graft	90 days	Combined open revision AND thrombectomy — report this code (not 36831 + 36832 separately) when both performed at same session
Dialysis Circuit Diagnostic & Interventional (Replaced 35476/75962–75968 in 2020)
36901	Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report	0 days	Diagnostic angiography of dialysis circuit (fistulogram); includes all imaging; base code — additional interventional codes added to 36901 when interventions performed at same session
36902	36901 plus transluminal balloon angioplasty, peripheral dialysis segment	0 days	Fistulogram + PTA of peripheral (non-central) stenosis in dialysis circuit; includes 36901 — do not report separately
36903	36901 plus transcatheter placement of intravascular stent(s), peripheral dialysis segment	0 days	Fistulogram + stent placement in peripheral dialysis circuit segment; includes 36901 and angioplasty
36904	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)	0 days	Pharmacomechanical thrombectomy of peripheral dialysis segment; includes diagnostic imaging — do not report 36901 separately
36905	36904 plus transluminal balloon angioplasty, peripheral dialysis segment	0 days	Thrombectomy + PTA of peripheral dialysis segment; includes 36904
36906	36904 plus transcatheter placement of intravascular stent(s), peripheral dialysis segment	0 days	Thrombectomy + stent placement peripheral segment; includes 36904 and 36905
36907	Transluminal balloon angioplasty, central dialysis segment (List separately in addition to code for primary procedure)	Add-on	Add-on code for central dialysis segment (central veins: subclavian, innominate, SVC) PTA; report with 36901–36906 as applicable
36908	Transcatheter placement of intravascular stent(s), central dialysis segment (List separately in addition to code for primary procedure)	Add-on	Add-on for central dialysis segment stent; report with 36901–36906
36909	Dialysis circuit permanent vascular embolization or occlusion (List separately in addition to code for primary procedure)	Add-on	Embolization/occlusion of accessory vessels, side branches, or competing venous outflow to augment maturation or treat steal; add-on to primary dialysis circuit code

⚠️ Common Pitfall — CPT 36901–36909 Bundling

The 36901–36909 dialysis circuit code family uses an additive/inclusive structure: each higher-level code includes all components of the lower-level codes. Do not report 36901 (diagnostic angiography) separately when a therapeutic intervention (36902–36906) is performed at the same session — the diagnostic component is already bundled. Similarly, 36907 and 36908 are add-on codes that must be reported in conjunction with a primary dialysis circuit code (36901–36906). Unbundling these codes is a major CPT audit risk.

12. HCPCS (2026)

HCPCS Code	Description	Typical Use / Notes
Q4081	Injection, epoetin alfa, 100 units (for ESRD on dialysis)	ESA administration for anemia in ESRD hemodialysis patients; billed per 100 units administered
J0882	Injection, darbepoetin alfa, 1 mcg (non-ESRD use); for ESRD on dialysis	Long-acting ESA (Aranesp); dosed less frequently than epoetin; used in hemodialysis patients for anemia management
J0887	Injection, epoetin beta, methoxy polyethylene glycol, 1 mcg	Mircera — continuous ESA; monthly dosing; for ESRD on dialysis anemia
J1439	Injection, ferric carboxymaltose, 1 mg	Injectafer — IV iron for iron-deficiency anemia in ESRD; high-dose formulation; commonly administered in dialysis units
J1443	Injection, ferric pyrophosphate citrate solution (Triferic), 0.1 mg of iron	Triferic — iron replacement specifically administered via dialysate during hemodialysis session; unique delivery route
J1444	Injection, ferric pyrophosphate citrate powder (Triferic AVNU), 0.1 mg of iron	Triferic AVNU — intravenous formulation of ferric pyrophosphate citrate; dialysis iron supplementation
A4651–A4932	Dialysis supplies (multiple codes)	Range covers dialysis-specific disposables including needles (A4651), blood tubing (A4750), dialyzers (A4690), water treatment supplies — typically bundled in ESRD composite rate per CMS ESRD PPS

📝 Coder Note — ESRD Composite Rate Bundling

Under the CMS ESRD Prospective Payment System (ESRD PPS) (expanded bundled payment effective 2011), most dialysis-related drugs and supplies — including ESAs, IV iron, and dialysis supplies (A4651–A4932) — are included in the ESRD composite rate and are not separately billable by dialysis facilities for Medicare patients. Exceptions apply for home dialysis patients and certain non-routine supplies. Separate billing of bundled items is a compliance risk. Always verify payer-specific billing rules for HCPCS codes in dialysis settings.

13. AHA Coding Clinic (Recent Guidance)

The following reflects relevant AHA Coding Clinic guidance applicable to AV fistula and dialysis access coding. Coders should verify the most current issue for updates:

Topic	Guidance Summary	Approximate Period
Coding dialysis access thrombosis vs. stenosis	When documentation supports thrombosis of an AVF or AVG, T82.868A is the appropriate code. T82.858A (stenosis) should be used when stenosis is the primary documented complication. Query the provider when documentation is ambiguous between thrombosis and stenosis.	Recent (refer to current Coding Clinic for specific volume/issue)
Z99.2 and N18.6 — dual coding requirement	Coding Clinic has confirmed that both Z99.2 (dependence on dialysis) and N18.6 (ESRD) should be assigned concurrently for dialysis patients. Z99.2 alone is insufficient to capture ESRD for HCC risk adjustment purposes.	Ongoing guidance
T82.7xxA — organism coding with graft infection	When an AVG infection results in bacteremia or sepsis, code the graft infection complication (T82.7xxA) as well as the causative organism or systemic infection (e.g., A41.01 Sepsis due to MRSA). The complication code does not capture the organism — both are required.	Ongoing guidance
Endovascular AVF creation (36836–36837)	Coding Clinic has addressed coding for percutaneous AVF creation; confirm that the documentation specifies the device system used (Ellipsys vs. WavelinQ) and number of access sites for accurate CPT selection between 36836 and 36837.	Post-2020
Steal syndrome coding	Steal syndrome associated with dialysis AV access is indexed to I77.1 for the arterial stricture/steal component. When ischemic complications of steal syndrome require additional coding (e.g., I74.x peripheral arterial thrombosis, gangrene), code those conditions additionally with appropriate sequencing.	Ongoing guidance
7th character selection for T82.x	Confirms that the 7th character selection (A, D, S) for T82.x complication codes is driven by phase of care — “A” (initial encounter) applies when active treatment is being provided, regardless of whether this is the patient’s first visit for the complication.	Ongoing per Section I.C.19 guidelines

14. HCC / Risk Adjustment (v28)

The following HCC mappings reflect CMS-HCC Model v28 (applicable to CY2026 risk adjustment). HCC capture for dialysis patients is one of the highest-impact areas in Medicare Advantage risk adjustment.

ICD-10-CM Code	HCC v28 Category	HCC Description	Approx. RAF Weight	CDI / Capture Notes
N18.6 (ESRD)	HCC 139	Dialysis Status	~0.436	Must be coded with Z99.2; requires annual documentation; highest renal HCC; see Renal/CKD CDG
Z99.2 (dialysis dependence)	HCC 139	Dialysis Status	~0.436 (additive when both coded)	Required at every encounter for dialysis patients; annual HCC capture critical for MA plans
N18.5 (CKD stage 5)	HCC 138	CKD, Stage 5	~0.236	Use when ESRD not yet established (GFR <15, not yet on dialysis); lower RAF than HCC 139
T82.7xxA (graft infection)	HCC 265	Major Complications of Medical and Surgical Care	~0.360	AVF/AVG infection; also triggers HCC 265 — document specificity of infection, organism, and access type
T82.868A (AVF/AVG thrombosis)	HCC 265	Major Complications of Medical and Surgical Care	~0.360	Thrombosis documented explicitly; captures HCC 265; distinguish from stenosis (T82.858A) for specificity
T82.858A (stenosis of vascular device)	HCC 265	Major Complications of Medical and Surgical Care	~0.360	Stenosis or thrombosis of vascular prosthetic device; commonly applied to AVF/AVG complications
I77.0 (acquired AVF — non-dialysis)	HCC 266	Vascular Disease	~0.290	Traumatic/pathological AVF only (NOT dialysis); maps to HCC 266 vascular disease
I74.2 (upper extremity arterial thromboembolism)	HCC 266	Vascular Disease	~0.290	Peripheral arterial embolism/thrombosis from steal syndrome or graft-related emboli

💬 CDI Query Trigger — HCC 139 Annual Capture

For every encounter with a dialysis patient (inpatient, outpatient, office), query or confirm documentation of both N18.6 (ESRD) and Z99.2 (dialysis dependence) if not already present in the record. These codes must be documented at least once per calendar year per patient in Medicare Advantage risk adjustment to ensure HCC 139 capture. Missing annual documentation for a dialysis patient represents a significant RAF gap (~0.436 per code, potentially ~0.872 combined). Coordinate with the chronic conditions monitoring process for all hemodialysis patients.

15. CDI Query Templates

All queries below are formatted per ACDIS / AHIMA compliant query standards: non-leading, multiple-choice, clinically supported. Queries should be used when documentation supports one of the listed options but does not explicitly state the condition.

Scenario / Trigger	Suggested Query Wording (Non-Leading, Multiple-Choice)
Documentation states “clotted fistula” or “loss of thrill/bruit” without specifying type of complication	“The patient presents with loss of AV fistula function. Based on your clinical assessment and available imaging, does the patient have: (a) Thrombosis of the AV fistula, (b) Outflow stenosis of the AV fistula, (c) Infection of the AV fistula, (d) Other complication (please specify), (e) Undetermined / clinically unable to differentiate at this time.”
Dialysis patient with ESRD — status not documented in current encounter	“This patient is on maintenance hemodialysis. Does the patient have: (a) End-stage renal disease (ESRD, N18.6) with dependence on hemodialysis (Z99.2), (b) Chronic kidney disease stage 5 (N18.5) not yet on dialysis, (c) Other kidney disease (please specify), (d) Clinically undetermined.”
Documentation of “fistula infection” without organism or systemic involvement specified	“The patient has a documented infection of the AV graft/fistula. Based on your clinical assessment and culture results, does the patient have: (a) Localized AV access infection without systemic involvement, (b) AV access infection with associated bacteremia (please specify organism if known), (c) Sepsis secondary to AV access infection (please specify organism), (d) Clinically undetermined.”
Documentation of hand pain/ischemia in dialysis patient with AVF	“This dialysis patient with an upper arm AV fistula has documented hand ischemia/pain. Based on your assessment, does the patient have: (a) Dialysis access steal syndrome (DASS) — arterial ischemia distal to AV access, (b) Peripheral arterial disease unrelated to dialysis access, (c) Diabetic peripheral neuropathy/ischemia, (d) Other vascular complication (please specify), (e) Clinically undetermined.”
Encounter for fistulogram/angioplasty without documented indication	“This patient underwent dialysis circuit angiography (fistulogram) and intervention. What was the clinical indication? (a) Outflow stenosis of the dialysis circuit (specify location: peripheral / central), (b) Thrombosis of the dialysis circuit, (c) Maturation failure of newly created AV fistula, (d) Routine surveillance angiography, (e) Other (please specify).”
Post-AVF creation — documentation does not specify configuration/location	“An AV fistula was created in this patient. Please clarify: (a) Radiocephalic (wrist) fistula — direct anastomosis, (b) Brachiocephalic (upper arm cephalic vein) fistula, (c) Brachiobasilic (upper arm basilic vein) with transposition, (d) Forearm vein transposition fistula, (e) Other configuration (please specify). Was this: (i) A native/autogenous fistula or (ii) A prosthetic/synthetic graft (AVG)?”
Central venous edema or facial swelling in dialysis patient with history of prior catheters	“This dialysis patient has ipsilateral arm edema and/or facial/neck swelling with a history of prior central venous catheter placement. Based on your clinical assessment and available imaging, does the patient have: (a) Central venous stenosis secondary to prior catheter placement (I87.1), (b) Superior vena cava (SVC) syndrome, (c) Venous outflow obstruction from another cause (please specify), (d) Clinically undetermined.”

16. Treatments (Clinical)

AV Fistula / Graft Creation

Selection of vascular access type follows a hierarchy per KDOQI Vascular Access Guidelines and the Fistula First initiative:

Native AVF — first choice; radiocephalic preferred; requires 6–12 weeks maturation
AVG (prosthetic graft) — when native veins are inadequate; usable in 2–4 weeks
Tunneled dialysis catheter (TDC) — last resort; highest infection and mortality risk; bridge to AVF/AVG creation

Endovascular AVF creation (Ellipsys, WavelinQ systems) offers a minimally invasive alternative to open surgery for selected patients with appropriate vessel anatomy, as described in published clinical trials.

Management of Thrombosis

Endovascular (preferred): Percutaneous transluminal thrombectomy (PTT) using mechanical thrombectomy devices ± pharmacomechanical thrombolysis (alteplase); followed by correction of underlying stenosis with PTA ± stent (CPT 36904–36906)
Open thrombectomy: CPT 36831 (without revision) or 36833 (with revision); used when endovascular approach fails or is unavailable
Timing: Best outcomes with treatment within 24–48 hours of thrombosis

Management of Stenosis

Percutaneous transluminal angioplasty (PTA): First-line for peripheral and central venous stenosis; high-pressure balloons required for mature stenoses; CPT 36902 (peripheral), 36907 (central)
Stent placement: Reserved for elastic recoil, post-PTA dissection, or recurrent/refractory stenosis; CPT 36903 (peripheral), 36908 (central); stent grafts preferred for central veins
Primary patency of PTA typically 50–60% at 12 months for AVG stenosis

Management of Steal Syndrome

DRIL procedure (Distal Revascularization-Interval Ligation): Bypass graft to restore distal perfusion with ligation of the artery between bypass anastomosis and fistula; gold standard for moderate-severe steal
PAI (Proximalization of Arterial Inflow): Move fistula inflow to a more proximal artery; reduces steal flow
Banding / RUDI (Revision Using Distal Inflow): Reduction of fistula diameter to decrease steal; simpler procedure
Access ligation: Last resort; access sacrificed to save limb

Management of Aneurysm / Pseudoaneurysm

True aneurysm: Conservative management for small, stable aneurysms; surgical resection with interposition graft for large, symptomatic, or rapidly enlarging aneurysms; skin thinning/threatened rupture is urgent indication for repair
Pseudoaneurysm: Ultrasound-guided compression or thrombin injection for small pseudoaneurysms; surgical repair for large, infected, or expanding pseudoaneurysms

Management of AVG Infection

Localized, early-stage graft infection: IV antibiotics, wound care — some cases amenable to graft salvage
Established/extensive graft infection: Partial or total graft excision required; IV antibiotics (6+ weeks for bacteremia/endocarditis)
Native fistula infections are rare but treated with IV antibiotics; rarely require surgical intervention

17. Patient Education / Summary

Key Documentation Concepts for Patient-Facing Coders and CDI Staff

When educating clinical staff and physicians on AV fistula documentation, the following points should be emphasized:

For Physicians / Nursing Documentation

Specify complication type: “Clotted fistula” is insufficient — document “thrombosis of AV fistula” or “outflow stenosis” explicitly
Document ESRD status at every encounter: Both “ESRD” and “hemodialysis dependent” (or “on dialysis”) must appear in the assessment/plan for HCC capture
Identify access type and location: “Upper arm brachiocephalic AV fistula” vs. “forearm radiocephalic AV fistula” vs. “upper arm ePTFE graft” — each drives different CPT codes
Note organism for infections: “MRSA bacteremia secondary to infected AV graft” captures significantly more than “infected access”

Patient-Facing Education Points

An AV fistula is your permanent “lifeline” for dialysis — it requires daily monitoring and careful needle care
Check your fistula daily: feel for the thrill (vibration) and listen for the bruit (humming sound); report any changes immediately to your care team
Protect your access arm: no blood draws, IV lines, or blood pressure cuffs on the fistula arm
Signs that require immediate medical attention: no thrill/bruit (possible clot), redness/warmth/swelling (possible infection), pain in hand during dialysis (possible steal), or sudden bulging at the fistula site
Your fistula typically needs 6–12 weeks to “mature” after surgery before it can be used for dialysis — a graft can usually be used sooner (2–4 weeks)

Quality & Compliance Context

Vascular access-related quality measures are tracked under the CMS ESRD Quality Incentive Program (QIP), including the AV Fistula rate measure and the catheter ≥90-day rate measure. Accurate coding of access type, complications, and interventions supports quality reporting and pay-for-performance outcomes for dialysis facilities. CDI specialists play a critical role in ensuring that dialysis access documentation reflects the clinical complexity of this patient population.

For complete guidance on ESRD, CKD staging, and hemodialysis encounter coding, refer to the companion Renal Failure / CKD / Dialysis CDG on the CCO Clinical Documentation Guides page.

About this Guide

This Clinical Documentation Guide is published by CCO Academy and is intended for credentialed coding, CDI, and clinical documentation professionals. Content is updated for FY2026 ICD-10-CM (effective October 1, 2025). All code assignments should be verified against the official ICD-10-CM Tabular List, AHA Coding Clinic, and applicable payer-specific policies. This guide does not constitute legal, medical, or compliance advice.

Last reviewed: April 2026 · Next scheduled review: October 2026 (FY2027 update)

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🔍 1. Definition