Anesthesia Coding Alert

The global anesthesia codes include many services, but when your anesthesiologist places a Swan-Ganz catheter, you'll need to know when you should -- and shouldn't -- report 93503 (Insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes) separately. Follow these expert tips to ensure your catheter coding is spot-on.

When your anesthesiologist is involved in an extensive heart procedure, he likely places a central venous pressure (CVP) catheter. The line is most often placed in the patient's superior vena cava, and may be used for other purposes, including IV fluid delivery, to adjust the patient's blood volume, or for central drug infusion.

In addition, your anesthesiologist may place a Swan-Ganz catheter (SGC), also known as a pulmonary artery (PA) catheter. This catheter can monitor pulmonary artery pressure, plus measure cardiac output and other cardiovascular functions. "Swan-Ganz is for specific monitoring," and central access, says Janice Lienhard, CPC, a coder in New Jersey. The SGC has multiple ports for central circulation access, including an regional anesthesia (RA) port, PA port, CVP port ,and possibly the main line or "introducer."

What it means to coding: If documentation shows that your anesthesiologist placed a PA catheter, you'll report 93503, in addition to the appropriate anesthesia code.

Reason: When an anesthesiologist places an SGC line, he runs it through the CVP line. So when the CVP line is inserted as part of the procedure of inserting an SGC, the CVP line is considered a component of the line placement, and is not reimbursable. Only the Swan-Ganz line is reimbursable, Lienhard says.

There are many instances where the physician will use both CVP line and a Swan-Ganz catheter in the same heart case for different reasons.

Example: Your anesthesiologist places a Swan-Ganz line in order to monitor cardiac output, and place a CVP line separately because of the need for multiple central vein IV access.

If two separate lines for the procedure are documented on the medical record, you can code both and expect separate reimbursement. Report 93503 and 36556 (Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older). Since you need to show that the CVP line is separate, append modifier 59 (Distinct procedural service) to 36556. If the insertion sites are different, this is an obvious indication that the CVP was separate from the SGC.

Roadblock: You can't assume that just because two lines were placed that you are reporting and billing for two codes. You should find clear documentation showing that your anesthesiologist placed a CVP line, followed by the Swan-Ganz, and note that the CVP was placed as part of the SGC insertion.

"If a coder doesn't realize these are done through the same access site, and that they aren't separately reportable when this happens, they will incorrectly add a 59 modifier to the CVP code and report both," says Leslie Johnson, CCS-P, CPC, director of coding and education with Medi Corp, Inc. in Cranford, N.J. and owner of the billing and coding Web site AskLeslie.net.

Your anesthesiologist might typically place a Swan-Ganz in patients who have some type of cardiac condition, or whose cardiac function might be compromised prior to or during surgery. Your anesthesiologist's documentation should include the specific reason the monitoring is necessary. A diagnosis such as congestive heart failure (428.0) would support the use of the Swan-Ganz monitor.