Question: What CPT code should I report for a smallbore catheter tunneled into the internal jugular vein? The patient is 38 years old.
Texas Subscriber
Answer: You should report 36558 (Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older). Providers may refer to this service as a “tunneled PICC.”
Watch for: For patients younger than 5 years of age, you would report 36557 (… younger than 5 years of age).
RS&I: If the physician uses ultrasound guidance for vascular access, you should also report +76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting [list separately in addition to code for primary procedure]).
Pay attention to the many requirements for this code in the descriptor, and be sure your documentation supports all of them.
If the physician instead uses fluoroscopic guidance, report +77001 (Fluoroscopic guidance for central venous access device placement, replacement [catheter only or complete], or removal [includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position] [list separately in addition to code for primary procedure]).
Reader Questions reviewed by Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C.
