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The Field Guide to Physician Coding 2nd Edition


General

Implantable Venous Access Port (CPT codes 36570, 36571, 36576, 36578)
Author: Nancy Maguire, ACS, PCS, FCS, HCS-D, CRT


An implantable port is a medical device that consists of two components. The first is a thin, soft, plastic tube called a catheter that is typically inserted (tunneled) under the skin of the chest and courses over the collarbone into a large neck vein. The catheter tubing connects to the second component called a reservoir that is implanted under the skin of the upper chest. The lack of precise physician documentation for these procedures causes confusion and frustration on the part of the coder.

Central venous access catheters and central venous access devices (VADs) are two different methods of venous catheterization.

Peripheral venous catheters are inserted into superficial veins, generally in the arms, legs, feet or head.

The tunneled catheters, or those that have ports or pumps, have moderate sedation included, as well as the non-tunneled for those patients under age 5. Non-tunneled, non-port/pump catheters generally do not require moderate sedation so that wasn't valued into the code. If you code moderate sedation separately for a peripherally inserted central catheter (PICC) line, make sure that medical necessity is documented and be prepared for a denial and appeal.

Flushing Of Vascular Access Port prior to administration of chemotherapy is integral to the chemotherapy administration and is not separately billable.

CPT codes 36570 and 36571 describe insertion of peripherally inserted central venous access device, with subcutaneous port; younger than 5 years of age (36570) or age 5 years or older (36571). The procedure involves creation of a subcutaneous pocket for placement of a completely implantable venous access device, but these catheters are laced in an extremity vein instead of a vein in the chest wall or neck. A guidewire is inserted by puncturing the basilica vein (in the arm) and centrally assed through the vein. A subcutaneous pocket is then created in the arm to implant the port device. The central venous catheter is then measured to proper length, placed and connected to the port device. Codes 36570-36571, include the definition "peripherally inserted [CVA] device, with subcutaneous port" and do not include "tunneling."

Peripherally inserted central venous catheter (AKA PICC line 36570 and 36571).
  • Nontunneled.
  • Includes subcutaneous port or pump with subcutaneous pocket.
  • Long-term use
Example:

A 3- year old patient is ordered PICC line for long-term IV infusions. A peripherally inserted cntral venous access catheter with subcutaneous port is placed. The basilica vein is punctured, catheter is measured and cut to proper length and then placed. A subcutaneous pocket is then created and the catheter is attached to the port. The port is secured in the pocket and the pocket is sutured.

Ultrasound guided, fluoroscopic guidance and still images of both these modalities, 36570 and 36571, (were used for revealing the right basilic vein to the patent. Fluoroscopic image was saved confirming proper position of the catheter tip at the upper right atrial level.

+77001 – fluoroscopic guidance for CVA device placement, replacement (catheter only or complete), or
removal. List separately with CVA placement code.

Includes fluoro guidance for:
  • Vascular access
  • Catheter manipulation
  • Contrast injections
  • Radiographic documentation of final catheter position
+76937 – ultrasound guidance for vascular access:
  • Evaluation of potential access sites
  • Selected vessel patency
  • Concurrent realtime U/S visualization
  • Permanent recording and reporting
  • List separately
CPT code 36575 “Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous port or pump; central or peripheral insertion site. In the context of code 36575, CPT defines “repair” as “fixing device without replacement of either  catheter or port/ pump, other than pharmacologic or mechanical correction of intracatheter or pericatheter occlusion.”

CPT code 36576 describes the repair of central venous access device, with subcutaneous port or pump, central or peripheral insertion site. A “repair” means something is broken. “Repair of central venous access device,with subcutaneous port or pump; central or peripheral insertion site”.

Code 36578 describes “replacement”, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site.

CPT codes 36576 and 36578 have a “Moderate sedation” icon before each code. This symbol is also noted on codes 36555, 36557, 36558, 36560-36568, 36570, 36571. Appendix G of the CPT manual contains a listing of CPT codes that include moderate sedation. This means moderate sedation is an inherent part of providing the procedure and are identified with a dot within a circle before the code. It would not be appropriate to report both the procedure code and the sedation codes 99143-99145, for the same physician.

Medical Necessity must be established by documentation in the medical record. There must be linkage to each procedure code billed. This is accomplished by assigning the proper ICD-9-CM diagnosis(s) code.

Because the principal ICD-9 diagnosis codes for patients receiving these procedures can vary widely, it is
critical that the documentation supports the assigned diagnosis to establish medical necessity.

Examples include:

996.1 – Mechanical complication

996.74 – Complication of vascular catheter

V58.81 – Removal or replacement of vascular catheter.

Medical Necessity:

Vascular access procedures are performed when patients need:
  • intravenous antibiotic treatment.
  • chemotherapy, or anti-cancer drugs.
  • long-term intravenous (IV) feeding for nutritional support.
  • repeated drawing of blood samples.
  • hemodialysis, a process used to treat patients whose kidneys are not working properly. It involves a special machine and tubing that removes blood from the body, cleanses it of waste and extra fluid and then returns it back to the body.
Access catheters may also be used for:
  • blood transfusions.
  • patients who have difficulty receiving a simple IV line.

American College of Surgeons
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