# Removal of two catheters, insert one



## hsmith67 (Apr 16, 2015)

Background: Patient has ESRD with malfunctioning peritoneal dialysis catheter. Presented to ED with fluid overload and my surgeon placed a non-tunneled central venous catheter (36556) Vas-Cath to allow emergent dialysis. 

Four days later.......the plan is to: 1) remove malfunctioning peritoneal dialysis catheter, 2) remove the non-tunneled central venous catheter placed four days prior as it was a temporary fix for emergent needs, and 3) insert a tunneled Cannon catheter as a long term solution for dialysis. 

My confusion is replacement codes (36578-36585) only accommodate replacement of identical catheters (tunneled replaced with tunneled, non-tunneled replaced with non-tunneled), but that is not what my surgeon did (he replaced non-tunneled with tunneled) and removed a peritoneal catheter.

Please help me code this:
....I proceeded to remove the 2 sutures that held the Vas-Cath to the side of the left neck. A guidewire was passed into the lumn of the Vas-Cath catheter and the catheter was withdrawn over the wire. The catheter was passed off the table. The skin overlying the entry site in the left internal jugular vein was anesthetized with 0.5% Marcaine with epinephrine. The skin was dilated with sequential dilation. The breakaway self-sealing introducer was placed over the wire and into position on the left side of the neck. The wire was removed. The Cannon catheter was placed through the lumen of the breakaway introducer and into position confirmed with fluoroscopy to be at the confluence of the superior and inferior vena cava in good position. The breakaway sleeve introducer was removed leaving the Cannon catheter in place. A track was mapped out on the left chest. A counter incision was made in the mid portion of the left chest where the catheter would exit the skin. A tunnel was placed from the incision up to the neck and the catheter was tunneled under the skin and exited the mid left chest. The catheter was adjusted to proper length and the end containing both the blue and red port was attached and secured to the end of the catheter. Both ports were flushed with normal saline solution. It showed good infusion and good withdrawal. Both ports were then heparinized with heparinized saline solution. The catheter was attached to the skin on the anterior chest with 2-0 silk into position. The small opening in the side of the left neck was closed with 3-0 Monocryl sutures. The surgical sites were cleaned, dry. OptiSeal was applied on the surface of the skin on the left side of the neck and a sterile dressing was placed over the catheter on the left chest. 

Next, the patient's abdomen was reprepped and draped in standard surgical fashion. The existing peritoneal dialysis catheter was located on the left side of the abdomen in the left paramedian several centimeters from the umbilicus. The end of the catheter was amputated with scissors. A 4 cm incision was made on the skin at the catheter site. Dissection proceeded using electrocautery to dissect the fibrous sheath from the subcuataneous tissue and fascia. A second fibrous sheath was identified and was dissected from the deep subcutaneous tissue and fascia. The second sheath was removed along the entire peritoneal dialysis catheter and passed off the table. The ends of the hole of the fascia was grasped with Kocher clamps and elevated. The suction was introduced into the abdomen and peritoneal fluid was suctioned out of the abdomen. The defect was closed with #1 Prolene.....

Any help is greatly appreciated!

Hunter Smith, CPC


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## cynthiabrown (Apr 17, 2015)

I really think the only thing you will be able to bill is insertion of tunnelled catheter


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## hsmith67 (Apr 17, 2015)

What about unlisted procedure codes and op note vs. billing only one CPT when 3 different procedures were performed?


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## cynthiabrown (Apr 20, 2015)

The replacement codes can only be used if the catheter is being replaced through the same venous access site. If a venous access device is placed in another site, then the appropriate placement code should be used.

A charge may be made for removal of a tunneled catheter. In contrast, non-tunneled catheter removal is included in the insertion charge.


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## cynthiabrown (Apr 20, 2015)

and look at 49421  and 49422  be sure to read parenthetical notes


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