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Field Guide to Physician Coding 3rd Edition



Central Lines # 1 (36555-36571) - Why, How, When and Then Some ……
Author: Nancy Maguire

In medicine, a central venous catheter ("central line", "CVC", "central venous line" or "central venous access catheter") is a catheter placed into a large vein in the neck (internal jugular vein ), chest (subclavian vein or axillary vein) or groin (femoral vein). It is used to administer medication or fluids, obtain blood tests (specifically the "mixed venous oxygen saturation"), and directly obtain cardiovascular measurements such as the central venous pressure. (From Wikipedia).

A central venous catheter, also called a central line, is a long, thin, flexible tube used to give medicines, fluids, nutrients, or blood products over a long period of time, usually several weeks or more. A catheter is often inserted in the arm or chest through the skin into a large vein. The catheter is threaded through this vein until it reaches a large vein near the heart. A catheter may be inserted into the neck if it will be used only during a hospital stay. Selecting the proper code depends on the patient’s age, whether the
surgeon places the catheter centrally or peripherally, where the catheter tip is at the end of placement, and whether the catheter is tunneled or non-tunneled. Do not choose based on catheter name. Surgeons typically place Hickman catheters as central lines, and they usually place them centrally, although they can be tunneled or non-tunneled.

Central – puncture into the jugular, subclavian, femoral vein or in the inferior vena cava.

Peripheral – basilic or cephalic vein.

A peripherally inserted central catheter or PICC line (say "pick"), is a central venous catheter inserted into a vein in the arm rather than a vein in the neck or chest. (36568, 36569 and device codes 36570 and 36571). The PICC is inserted into large vein in the arm and advanced forward into the subclavian vein.

The CPT guidelines tell us that in order to qualify as a central venous access catheter or device, “the tip of the catheter/device must terminate in the subclavian, brachiocephalic (innominate), or iliac veins, the superior or inferior vena cava, or the right atrium.” The catheter can be inserted centrally (in the jugular, subclavian, femoral vein or inferior vena cava catheter site) or peripherally (via the basilic or cephalic vein). The device may be accessed for use either via exposed catheter (external to the skin), via a subcutaneous port or via a subcutaneous pump.

The procedure codes involve: insertion, repair, partial replacement, complete replacement, or the removal of the entire device. Documentation should answer the type of procedure performed: Tunneled, centrally inserted; Tunneled, peripherally inserted; Non-tunneled, centrally inserted; or, peripherally inserted.

CPT codes 36555-36569 describe the insertion of Non-Tunneled and Tunneled centrally inserted central venous catheter(s). The age of patient: greater or less than 5 years old must be identified. When imaging is used for these procedures, either for gaining access to the venous entry site or for manipulating the catheter into final central position, use 76937 (ultrasound guidance), or code 77001 (Fluoroscopic guidance). The imaging codes are “add-on” codes to the main procedure performed. The main point and the key to reporting these services is always documentation. Codes 36570 and 36571 identify the peripherally inserted device.

Critical Care codes 99291 and 99292 must be considered if the patient’s condition warrants this service. Critical illness or injury is an illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition. Peripheral vascular access procedures (CPT 36000, 36410, 36415, 36591, 36600) are bundled into Critical Care Codes 99291 and 99292. Any services performed that are not listed may be reported separately. So, if code 36556 (Insertion of non-tunneled central venous catheter, age 5 years or older) is performed as well as 99291 (1st hour of critical care), it can be codes separately.

Modifier -25 can only be placed on an E/M code to designate a minor procedure was also performed in addition to critical care. Critical care services provided to a patient may not be paid by some payors (eg Medicare) on the same day the physician also bills a non-bundled procedure code(s), example, central line, unless critical care is billed with the CPT modifier -25 to indicate that the critical care is "a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative care associated with the procedure that was performed. For such payors, when services such as central line, endotracheal intubation (CPT code 31500) and CPR (CPT code 92950) are provided, separate payment may be made for critical care in addition to these services if the critical care was a significant separately identifiable service and it was reported with modifier -25. The time spent performing the pre, intra, and post procedure work of these unbundled services is excluded from the determination of the time spent providing critical care. So, you have to do the math first for critical care time.

A Tunneled catheter is surgically inserted into a vein in the neck or chest and passed under the skin. Only the end of the catheter is brought through the skin through which medicines can be given. Passing the catheter under the skin helps keep it in place better, lets the patient move around easier, and makes it less visible. Name brand examples may include: Hickman catheters (brand name; dual-lumen catheters used for TPN, blood products, chemotherapy, large-lumen Hickmans can be placed for dialysis/apheresis); Broviac catheters (brand name; similar to Hickmans); Groshong catheters (brand name; characterized by its valve-ended tip rather than an open-ended tip like all other catheters, requires less frequent line flushing). Tunneled catheters are often referred to by their brand names (Groshong, Hickman, etc.) as this also connotes their functionality.

Ports are tunneled catheters implanted completely under the skin. The port must be accessed through the skin with a special Huber needle in order to use. Ports are placed for long-term though relatively infrequent venous access, particularly if treatment will be >6 months. Ports are used primarily for weekly/monthly chemotherapy administration.

Tunneled catheter with Subcutaneous Pump (36563): Infusion pumps may be used to give some types of chemotherapy. There are various types of portable pumps. These give a controlled amount of chemotherapy, for example, into the bloodstream over a period of time (from a few days to a few weeks). The pump is connected to a central line or a PICC line.

Tunneled catheter with 2 catheters via 2 separate venous access sites: with or without subcutaneous ports (36565 or 36566).

Tunneled catheters must identify the following details: tunneled without port or pump; central tunneled; tunneled with port or tunneled with pump. Documentation will be critical to accurate code selection.

A non-tunneled central line is also called a catheter. A catheter is a small flexible plastic tube. Catheter is placed directly into venous system. The catheter then goes into a vein in the neck or near the collarbone. The catheter ends in a vein by the heart. A vein is a tube inside the body that carries blood from the body to the heart.

Non-Tunneled Catheters are used to give medicines and other fluids they are placed for short-term central venous access for particular therapies (pressors, aggressive IV fluid resuscitation, central venous pressure monitoring). A non-tunneled central line can also be placed for short-term hemodialysis/apheresis, (Quinton catheters) and hemodynamic monitoring (Cordis with Swan-Ganz catheter). They are generally referred to by their site of placement (internal jugular, subclavian, femoral). Non-tunneled catheters are uncuffed and provide direct access into the vein; they may be removed at any time if indicated. These catheters are traditionally dual- or triple-lumen catheters; there is a mildly increased thrombotic risk with larger lumen catheters (true for all catheters). Non-tunneled catheters will reference codes 36555, 36556, 36568, 36569. Non-tunneled device maps to codes 36570 and 36571.

The CPT manual has a Central Venous Access Procedures Table in the Surgery/Cardiovascular System and should be referenced when coding these services.

The National Correct Coding Initiative is an invaluable resource when coding multiple services.

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