Vol. 14 •Issue 24 • Page 9
Coding Central Venous Access
As you review the following, note the phrases in boldface type. These can help you arrive at the appropriate CPT code assignment(s). Be sure to select the code(s) before you look at the answer.
This 72-year-old patient with acute respiratory failure and renal failure requires hemodialysis and IV access. We have been asked to place a double lumen tunneled catheter and PICC line.
The procedures, risks, benefits and alternatives were explained to the patient’s family, and written informed consent was obtained.
Upon beginning the procedure, the patient was hypotensive with systolic blood pressures in the 60s and hypoxic with 02 saturations in the 80s. At the time it was decided to begin with a non-tunneled right IJ catheter and then proceed as the patient’s condition permitted. Dopamine was increased during the procedure.
Patient is placed supine on the fluoroscopic table then prepped and draped in the usual sterile fashion. 1 percent Lidocaine was used for local anesthesia. Under ultrasound guidance, a micropuncture needle was used to access the right internal jugular vein, and a .018 wire was placed through the needle. The needle was removed then three and four French dilators were advanced over the wire. The wire and inner dilator were removed. A J-wire was placed through the outer dilator, which was then removed. A dual lumen non-tunneled 16 cm catheter was advanced over the wire and positioned with the tip at the region of the cavoatrial junction. The wire was removed, and a catheter noted to flush and withdraw easily. The catheter was flushed with heparin and sewn in place with 2-0 silk and dressed in the usual sterile fashion.
Attention was turned to the left arm, which was prepped and draped in the usual sterile fashion. 1 percent Lidocaine was used for local anesthesia. Under ultrasound guidance, access was obtained to a left antecubital vein with a micropuncture needle, and a 0.18 wire was placed through the needle. The needle was removed, and the dilator and peel-away sheath were advanced over the wire. The wire and inner dilator were removed. A dual lumen PICC line was advanced through the peel-away sheath with the tip remaining in the most superior aspect of the SVC. This was flushed, capped and dressed in the usual sterile fashion.
Successful placement of a non-tunneled right IJ catheter and a left antecubital dual lumen PICC as described. A non-tunneled catheter was placed, as the patient was unstable at the beginning of the procedure. Patient became more stable after placement of the non-tunneled catheter, and, therefore, the PICC line was placed at that time.
CPT Code Assignments
Assign code 36569 for the peripherally inserted central venous catheter.
36569 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; age 5 years or older
Assign code 36556 for the centrally inserted central venous catheter.
36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older
Had the physician provided complete documentation of the imaging guidance portion of the procedure performed above, another code could have been legitimately assigned. To allow this assignment, the documentation should have included a statement such as the following: “Ultrasound evaluation of potential access sites was performed. After successfully identifying a patent vessel, ultrasound guidance was used to puncture the vessel. A permanent recording was created for the patient record.”
If this information had been present for both the central and peripheral insertions, the following code could have been assigned twice. Modifier Ð59 or modifier -76 would need to be added (based upon payer preference and/or requirements) to describe that the guidance was used a second time in a separate anatomical site.
76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure.)
Code 75998 also could have been assigned if the documentation had been comprehensive. Although the above document does not state the use of fluoroscopic guidance, it had to be used because it would be technically impossible to determine the final catheter placements without it.
As always, codes assigned depend on actual documentation, not the assumed procedure. The physician should have indicated that fluoroscopic guidance was used and should have documented that the final catheter placement was performed with the help of fluoroscopy or filming.
Jeff Majchrzak is vice president of radiology services and a senior healthcare consultant for Medical Learning Inc. (MedLearn®), St. Paul, MN.