# Vascular access



## prabha (Apr 15, 2009)

My codes for the following procedure are 

36000(brachial)
76937-26
36000-59(jugular)
77001-26
76937-2659.  Can anyone pls confirm whether this is correct.

 Procedure: Ultrasound-guided venous access and limited central
      venography.

      History:    64 year old male with history of end-stage renal
      disease, hemodialysis dependent.  The patient has known history of
      central venous occlusions, and currently receives dialysis via a
      tunneled, double lumen right groin dialysis catheter. Referred
      for PICC placement if possible or ultrasound guided venous access.

      Procedure: A preliminary 
      ultrasound scan of the right upper arm was performed demonstrating
      patent questionable, diminutive brachial vein.  With the patient
      in the supine position the right upper arm was prepped and draped
      in a sterile fashion and the skin and subcutaneous tissues were
      infiltrated with local Lidocaine.  Under real time ultrasound
      guidance, the right brachial vein was punctured numerous times
      with a 21 gauge needle.  A permanent sonographic recording was
      created for the patient's medical record.  A  0.018 inch guidewire
      was inserted through the needle, however, would not advance
      further within the vein.  Further attempts of venous access via
      the right arm were reported.

      Preliminary sonography of the left neck demonstrates a widely
      patent internal jugular vein, however, no external jugular vein is  
      visualized.  The left neck and upper chest were prepped and draped
      in usual sterile fashion.  1% lidocaine was administered to the
      skin and subcutaneous tissues.  Using real-time sonographic
      guidance, the left internal jugular vein was punctured with a
      21-gauge needle.  A permanent sonographic recording was created
      for the patient's medical record.  Under fluoroscopic guidance, a
      0.018 inch wire was advanced through the needle, however, would
      not advance centrally within the chest.  Exchange was made for the
      4-French micro-puncture introducer.  Limited venography was then
      performed, demonstrating total central venous occlusion, with
      numerous, abnormal collaterals throughout the paracervical and
      intercostal regions.

      The 4-French micropuncture introducer was then left within the
      left internal jugular vein, to serve as central venous access for
      antibiotic therapy.  The introducer was flushed with Hep-Lock
      solution and secured to the skin with sterile dressings.

      The patient tolerated the procedure well and no complications were
      encountered.  Total fluoroscopy time was 1.0 minutes.
      Approximately 20 cc of Isovue 300 were used as intravascular
      contrast.

      Impression:
      Limited left central venography demonstrates complete occlusion at
      the origin of the brachiocephalic vein with numerous venous
      collaterals about paracervical and intercostal regions.

      Ultrasound and fluoroscopy guided placement of a 4 French
      micropuncture introducer through the left internal jugular vein
      without complication.


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## msncoder (Apr 15, 2009)

Prabha,
  Who are you billing for? The radiology codes would be 36556, 76937-26, and 77001-26 (the venogram is only performed to localize the veins to place the CVC so it is considered part of the CVC plcmt). The venipuncture codes are not billable separately either.
Anita Elder, CIRCC, CPC, RCC
radcoder4msn@yahoo.com


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## prabha (Apr 16, 2009)

*vascular access*

Hi Anita,

We bill for physician.My question is, in this case where the physician has punctured the jugular vein, he has not placed the tip of the catheter in subclavian, brachiocephalic,iliac vein or the superior or inferior vena cava.So,how can we code it as 36556? whereas the tip of a centrally inserted catheter should terminate in any one of these veins.


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## msncoder (Apr 16, 2009)

*Vascular Access*

Prahba,
  My apologies! I totally missed that crucial bit of information (some coder I am, huh??!!). From my understanding of an article in Clinical Examples in Radiology, if the cath stops in "midline" then you would use the PICC or CVC code with a 52 modifier. CPT 36000 looks like it would work as well however the RVUs are significantly lower and from the amount of work your physician provided I would want to obtain them the highest reimbursement possible (legally).


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