No office rate
36832 describes open revision of an AV fistula without thrombectomy. Choose 36838 when the operation instead performs the DRIL bypass and interval ligation for access-related hand ischemia.
On this page
CMS RVU26D · Effective 2026-10-01
36838 Access revascularization Medicare reimbursement rates in Hawaii
Reports an upper-extremity DRIL operation that restores hand perfusion compromised by hemodialysis access while preserving the access. Compare 36838 office and facility rates across CMS payment localities in Hawaii.
Amounts below use the non-QP conversion factor for participating physicians. These are base physician payments before claim-level adjustments, not patient costs or total hospital charges.
What does Medicare pay for 36838 in Hawaii?
Hawaii has 1 payment locality in this comparison. Use the service location to choose the applicable amount. These are the supported base rates for the payment area shown below, using the same CMS release.
Office / nonfacility
No supported rate
Facility setting
$974.35
1 of 1 localities have a supported rate.
Payment area: Hawaii, Guam
One mapped payment locality.
These are locality ranges, not averages or address-specific quotes. A facility-setting amount covers the physician service; it does not include a hospital’s separate bill. Choose a locality below to inspect its calculation, compare other payment areas, or price a percentage of Medicare.
Vascular surgery
About 36838: Distal revascularization for dialysis access steal
Reports an upper-extremity DRIL operation that restores hand perfusion compromised by hemodialysis access while preserving the access.
This operation treats hand ischemia associated with an upper-extremity hemodialysis access. The surgeon creates an arterial bypass to restore blood flow to the hand beyond the access and ligates the native artery between the access and the distal bypass connection. The approach is intended to relieve access-related diversion of blood while keeping the dialysis access usable. Vascular surgeons typically perform it in an operating room for patients with clinically significant access-related ischemia.
Report 36838 when the operative work includes the distal revascularization and interval ligation procedure; document the ischemic problem, its relationship to the access, and the bypass and ligation performed. This major surgery has a 90-day global period, including the day-before preoperative visit and 90 days of related postoperative care. When performed bilaterally and reported with modifier 50, payment is at 150%. For multiple procedures in the same session, the highest-valued procedure is paid in full and others at 50%. An assistant at surgery may be paid; co-surgeons require supporting documentation, and team surgery is not permitted.
CMS billing rules for 36838
- Global period
- Major surgery with a 90-day global period: the day-before preoperative visit and 90 days of related postoperative care are included.
- Multiple procedures
- Standard multiple procedure reduction: the highest-valued procedure is paid in full and others at 50% when performed in the same session.
- Bilateral procedures
- Bilateral procedure with modifier 50 is paid at 150%.
- Assistant at surgery
- Assistant at surgery may be paid.
- Co-surgeons
- Co-surgeons paid only with supporting documentation.
- Team surgery
- Team surgery not permitted.
Where the value comes from
- Work RVU21.15 · 69%
- Practice expense (office) RVU4.31 · 14%
- Malpractice RVU5.39 · 17%
284
Medicare services in 2024 · #4034 by national volume
This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.
36838 compared with similar codes
Office rates for Hawaii, from the same CMS release.
No office rate
36833 is open AV fistula revision with thrombectomy. It does not describe the DRIL bypass and interval ligation that define 36838.
No office rate
36831 describes thrombectomy of an AV fistula without revision. Report 36838 for the access-related ischemia operation, not simply to describe clot removal.
Compare 36838 by payment locality
Find the payment area for your service address, then open its rate page for calculation inputs, release history and the percentage-of-Medicare tool. A city may cross payment-area boundaries; the ZIP lookup above helps resolve the location.
1 of 1 payment localities
Hawaii, Guam →
Office / nonfacility
Unavailable
Facility
$974.35
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How this local rate is calculated
Each RVU component is multiplied by its own geographic practice cost index (GPCI). The three adjusted components are added, then multiplied by the conversion factor. These are the inputs used for 36838 in Hawaii, Guam.
PPRRVU2026_Oct_nonQPP.csv
4,559
- Code
- 36838
- Physician work
- 21.15
- Practice expense
- 4.31
- Malpractice
- 5.39
GPCI2026.csv
46
- Locality
- Hawaii, Guam
- Physician work
- 1.000
- Practice expense
- 1.137
- Malpractice
- 0.579
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 21.15 | × 1.000 | 21.1500 |
| Practice expense | 4.31 | × 1.137 | 4.9005 |
| Malpractice | 5.39 | × 0.579 | 3.1208 |
| Total RVUs | 29.1713 | ||
| Conversion factor | × 33.4009 | ||
Facility rate, Hawaii, Guam$974.35
Explore RVUs, geographic factors and the full formula
Facility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 21.15 | 1 |
| Practice expense | 4.31 | 1.137 |
| Malpractice | 5.39 | 0.579 |
(21.15 × 1 + 4.31 × 1.137 + 5.39 × 0.579) × $33.4009 = $974.35
The office and facility calculations use their respective practice-expense RVUs. The facility amount here is the physician fee, not a separate hospital or facility bill.
36838 billing questions
When should 36838 be chosen over an AV fistula revision code?
Use 36838 when the surgeon performs the DRIL bypass and interval ligation to address access-related hand ischemia. Use a revision code when the documented operation is access revision rather than this revascularization procedure.
Is the bypass reported separately from 36838?
The bypass and interval ligation are the defining work of the DRIL procedure reported by 36838. The operative report should describe those steps rather than treating them as unrelated services.
What documentation supports reporting 36838?
Document the upper-extremity dialysis access, the access-related ischemic symptoms or findings, and the arterial bypass and interval ligation performed to restore distal perfusion.
How does the 90-day global period affect postoperative billing?
The day-before preoperative visit and 90 days of related postoperative care are included in the global period. The global period applies to this major surgery.
Can 36838 be reported bilaterally?
When the procedure is performed on both sides, the CMS rule specifies modifier 50, with payment at 150%.
Can an assistant or co-surgeon be reported?
An assistant at surgery may be paid. Co-surgeons are paid only when supporting documentation is provided; team surgery is not permitted.
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense, and malpractice RVUs, adjusted by each locality’s geographic indices and the applicable conversion factor. Unavailable or separately priced services are labeled rather than assigned a made-up amount.
Source: RVU26D. Effective 2026-10-01 through the day before 2027-01-01.
4,55636835,,Insertion thomas shunt,A,,7.32,5.11,NA,5.11,,1.84,14.27,14.27,0,090,0.09,0.84,0.07,2,0,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
4,55736836,,Prq av fstl crtj uxtr 1 acs,A,,7.02,232.45,,1.34,,1.03,240.50,9.39,0,000,0.00,0.00,0.00,2,0,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
4,55836837,,Prq av fstl crt uxtr sep acs,A,,9.07,261.75,,1.52,,1.41,272.23,12.00,0,000,0.00,0.00,0.00,2,0,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
4,55936838,,Dist revas ligation hemo,A,,21.15,4.31,NA,4.31,,5.39,30.85,30.85,0,090,0.09,0.84,0.07,2,1,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
4,56036860,,External cannula declotting,A,,1.96,5.26,,0.47,,0.51,7.73,2.94,0,000,0.00,0.00,0.00,2,0,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
4,56136861,,Cannula declotting,A,,2.46,0.59,NA,0.59,,0.65,3.70,3.70,0,000,0.00,0.00,0.00,2,0,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
4,56236901,,Intro cath dialysis circuit,A,,3.28,16.76,,0.62,,0.51,20.55,4.41,0,000,0.00,0.00,0.00,2,0,1,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
4309102,FL,99,REST OF FLORIDA,1.000,0.956,1.503
4410212,GA,01,ATLANTA,1.003,1.016,1.201
4510212,GA,99,REST OF GEORGIA,1.000,0.892,1.192
4601212,HI,01,"HAWAII, GUAM",1.000,1.137,0.579
4702202,ID,00,IDAHO,1.000,0.920,0.473
4806102,IL,16,CHICAGO,1.007,1.005,2.295
4906102,IL,12,EAST ST. LOUIS,1.000,0.920,2.014