# central line removed and inserted twice



## efuhrmann (Sep 29, 2009)

On 9/14/09 right int jug hemodialysis catheter removed and replaced with a temporary catheter on the other side, in her left internal jugular.  On 9/18/09 the temporary catheter was removed and replaced.  The dilator and pull-away sheath was inserted in the Seldinger fashion in the right internal jugular.  Perma-Cath was inserted through the pull away sheath.  All done under fluoroscopic guidance.  Do I code remove and insert on both days?


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## dpeoples (Sep 29, 2009)

efuhrmann said:


> On 9/14/09 right int jug hemodialysis catheter removed and replaced with a temporary catheter on the other side, in her left internal jugular.  On 9/18/09 the temporary catheter was removed and replaced.  The dilator and pull-away sheath was inserted in the Seldinger fashion in the right internal jugular.  Perma-Cath was inserted through the pull away sheath.  All done under fluoroscopic guidance.  Do I code remove and insert on both days?




Can you provide the reports?


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## efuhrmann (Sep 29, 2009)

Procedure #1:
preop diag: bacteremia with line sepsis
postop diag:  bacteremia with line sepsis with ESRD requiring hemodialysis
Ultrasound guidance was used to isolate the internal jugular vein, and under us guidance, the internal jugular was cannulated.  A J-wire was placed under fluoroscopic guidance through the jugular vein and into the superior vena cava junction.  This was followed by appropriate dilatation, and in the Seidinger technique the catheter was placed.  Radiographic findings revealed no pneumothorax s/p line placement.  On ultrasound guidance, the left internal jugular was of excellent caliber without obvious stricture.

Procedure #2:
Procedure:  Exchange of left internal jugular temporary hemodialysis catheter for insertion of left internal jugular Perma-Cath placement under fluoroscopic guidance.
Initially local was injected in the tunnel area.  A counter-incision was made over her left anterior chest wall.  The Permacath device was tunnelled through this area to the opening of the old internal jugular catheter.  A wire was placed through the old internal jugular catheter to the inferior vena cava.  The old catheter was removed.  The dilator and pull-away sheath was inserted in the Seidinger fashion in the right internal jugular.  The wire was removed and the permacath was now inserted through this pullaway sheath.  The sheath was removed.  This was all done under fluoroscopic guidance.


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## Jim Pawloski (Sep 29, 2009)

efuhrmann said:


> Procedure #1:
> preop diag: bacteremia with line sepsis
> postop diag:  bacteremia with line sepsis with ESRD requiring hemodialysis
> Ultrasound guidance was used to isolate the internal jugular vein, and under us guidance, the internal jugular was cannulated.  A J-wire was placed under fluoroscopic guidance through the jugular vein and into the superior vena cava junction.  This was followed by appropriate dilatation, and in the Seidinger technique the catheter was placed.  Radiographic findings revealed no pneumothorax s/p line placement.  On ultrasound guidance, the left internal jugular was of excellent caliber without obvious stricture.
> ...



What I am assuming or hoping that the patient had the temporary dialysis catheter placed, went to hemodialysis, then came back for the long term hemodialysis catheter placement.  I would code it  for the short term dialysis catheter (36556/ 77001), then exchange for long-term dialysis (36581/77001).
Although the doctor says that ultrasound was used, make sure he says that a hard copy image was taken, so you can charge for the U/S.

HTH
Jim Pawloski CIRCC, R.T. (CV)


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## dpeoples (Sep 29, 2009)

efuhrmann said:


> Procedure #1:
> preop diag: bacteremia with line sepsis
> postop diag:  bacteremia with line sepsis with ESRD requiring hemodialysis
> Ultrasound guidance was used to isolate the internal jugular vein, and under us guidance, the internal jugular was cannulated.  A J-wire was placed under fluoroscopic guidance through the jugular vein and into the superior vena cava junction.  This was followed by appropriate dilatation, and in the Seidinger technique the catheter was placed.  Radiographic findings revealed no pneumothorax s/p line placement.  On ultrasound guidance, the left internal jugular was of excellent caliber without obvious stricture.
> ...



_*I would code this 36589 for removal of old cath, 36558/77001 for new tunnelled cath (first was not  tunnelled so this is not an exchange IMO), and 76937 if there was a permanent image taken.*_


HTH


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## efuhrmann (Sep 29, 2009)

Is there more info to read or can you explain what is required to bill this 76937?  I just love it when these secret codes pop up with special coverage issues!


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## Jim Pawloski (Sep 30, 2009)

dpeoples said:


> _*I would code this 36589 for removal of old cath, 36558/77001 for new tunnelled cath (first was not  tunnelled so this is not an exchange IMO), and 76937 if there was a permanent image taken.*_
> 
> 
> HTH



I was checking my resources (SIR coding book and Z-health Interventional book) and found that with this exchange, you cannot bill for the removal.  So all we can bill is for the tunnelled cath placement, 36558/77001.  

Have a good day everyone,
Jim


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## caroline75771 (Nov 3, 2009)

*Permcath removal during global period*

Hi All,

Would anyone know if I need to use a modifier with cpt code 36589 (done on 9/10/09) if procedure was done in the office and within the global period.    Physician had performed an left rad-ceph AVF and Tenchkoff catheter on 7/27/09 (36821 & 49421- 90 day global period).

Thank you...


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