Anesthesia Coding Alert

CPT 2004 Update:

Accommodate Overhaul of Venous Catheter Codes Before Submitting Your Next Claim

Published on Fri Nov 07, 2003

Pay special attention to catheter, PICC changes

Updates of interest to anesthesia coders for 2004 include three new anesthesia codes, one revised anesthesia code, and more than 20 new or revised codes related to PICC lines, venipuncture and catheter insertion or repair. CPT 2004 goes into effect on Jan. 1, 2004.

Get Specific With Updated One-Lung Ventilation and Pelvic Anesthesia Codes

CPT 2004 doesn't include many anesthesia-specific code changes, but the ones that were made are welcome additions that will make your coding job easier.

New code 00529 (Anesthesia for closed chest procedures; mediastinoscopy and diagnostic thoracoscopy utilizing one-lung ventilation) ties in with 00528, which CPT 2004 revised to specify that it does not include one-lung ventilation (the new descriptor is Anesthesia for closed chest procedures; mediastinoscopy and diagnostic thoracoscopy not utilizing one-lung ventilation).

"One-lung ventilation is fairly new, and CPT is updating the codes to reflect the added risk involved," says Barbara Johnson, CPC, MPC, coder with Loma Linda University Medical Anesthesiology Group in Loma Linda, Calif. "Most of the mediastinoscopy and diagnostic thoracoscopy we've been seeing are without one-lung ventilation, but that may be partly because it wasn't mentioned since it wasn't billable."

Codes for pelvic procedures expand with the addition of 01173 (Anesthesia for open repair of fracture disruption of pelvis or column fracture involving acetabulum). Now you'll use this instead of 01120 (Anesthesia for procedures on bony pelvis) or 01170 (Anesthesia for open procedures involving symphysis pubis or sacroiliac joint) for open repair of pelvic or column fracture and will be describing the procedure more accurately, says Debbie Gulledge, CPC, of Anesthesia Associates of Rockhill in Charlotte, N.C. You'll continue to report 01120 and 01170 for other bony pelvis cases that don't fall under 01173.

The final anesthesia addition is 01958 (Anesthesia for external cephalic version procedure). This explains the procedure much better than 01960 (Anesthesia for vaginal delivery only), which was your first option for cephalic version, or 01967 (Neuraxial labor analgesia/anesthesia for planned vaginal delivery [this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor]).

Information regarding base units for the new codes was not available when Anesthesia Coding Alert went to press. The ASA and the Federal Register both publish base units for all anesthesia codes, so stay tuned for future articles regarding the release of this information.

Check Venipuncture, Post-Op Revisions

People often ask if they can code for venipuncture when the anesthesiologist is called to perform a difficult stick. CPT 2004 helps answer this question by expanding the descriptors for two common venipuncture codes.

36400 (Venipuncture, under age 3 years, necessitating physician's skill, not to be used for routine venipuncture; femoral or jugular vein) - Adding the distinction of "necessitating physician's skill," CPT clarifies that this code is for special circumstances, not routine sticks. The change also applies to indented codes 36405* (... scalp vein) and 36406 (... other vein). Even with the physician-specific wording, you'll still be reimbursed two units for the code.

36410 (Venipuncture, age 3 years or older, necessitating physician's skill [separate procedure], for diagnostic or therapeutic purposes [not to be used for routine venipuncture]) - This code previously stated that it was for "child over age 3 years or adult." The updated wording simply clarifies that the code applies to anyone over age 3, not just young children or adults.

99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason[s] related to the original procedure) - CPT 2004 really expands this descriptor from its previous wording of "Postoperative follow-up visit, included in global service." Some coders believe that CPT changed it to prevent people from billing 99024 for office visits. "Adding 'global service' to the descriptor makes it clear that this is a nonbillable service," Johnson says.

You'll also be interested in several new and revised codes related to injections, neurolytic agent destruction, myelography, and pump refilling and maintenance. Check out the December 2003 issue of Pain Management Quarterly for more details on those areas.

Big Changes for Central Venous Catheter Codes

Reporting any services related to central venous catheters will be much more detailed now, thanks to an abundance of new codes in CPT 2004. These additions are balanced by several deletions of old venipuncture codes such as 36488-36491 (various codes associated with Placement of central venous catheter [subclavian, jugular, or other vein] [e.g., for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy], based on the patient's age and whether the physician uses a percutaneous or cutdown approach).

As you consider the differences, remember what distinguishes each venous catheter placement approach. Anesthesiologists usually place lines percutaneously for immediate use; in this case, the anesthesiologists don't tunnel the lines. If the line will be used for prolonged periods, however, tunneling the catheter under the skin adds a bit of work to the procedure but makes it more difficult for bacteria to migrate along the catheter into the blood stream. The term "subcutaneous port" means the whole catheter is under the skin and is less likely to get contaminated. The physician normally uses the approach for a catheter that will be present for longer periods; he usually needs some type of surgical privilege to place a subcutaneous port.

Some of the differences between codes are subtle, so they're underlined in the following sections.

Percutaneous (or nontunneled) insertions are the easiest for physicians to place. New percutaneous insertion codes include 36555 (Insertion of non-tunneled centrally inserted central venous catheter; under 5 years of age) and 36556 (... age 5 years or older).

Tunneled insertions are more involved but make it more difficult for bacteria to migrate along the catheter to the blood stream. CPT 2004 adds several codes related to tunneled insertions, including:

36557 - Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; under 5 years of age

36558 - ... age 5 years or older

36560 - Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; under 5 years of age

36561 - ... age 5 years or older

36563 - Insertion of tunneled centrally inserted central venous access device, with subcutaneous pump

36565 - Insertion of tunneled centrally inserted central venous access device, requiring two catheters via two separate venous access sites; without subcutaneous port or pump (e.g., Tesio type catheter)

36566 - ... with subcutaneous port[s].

Four other additions are for peripherally inserted catheter, or PICC, line codes: 36568 (Insertion of peripherally inserted central venous catheter [PICC], without subcutaneous port or pump; under 5 years of age) and 36569 (... age 5 years or older) for nonport placements and 36570 (Insertion of peripherally inserted central venous access device, with subcutaneous port; under 5 years of age) and 36571 (... age 5 years or older) for port placements.

Watch New Codes for Repair, Removal, Insertion

CPT 2004 includes several new codes for repair, replacement and removal of various catheters.

The two new repair codes 36575 (Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous port or pump, central or peripheral insertion site) and 36576 (Repair of central venous access device, with subcutaneous port or pump, central or peripheral insertion site) are based on whether the physician inserts a subcutaneous port or pump.

Most of the new codes in this area deal with central venous access device or catheter replacement. Use code 36578 (Replacement, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site) for catheter replacement of any central venous access device.

One code (36580, Replacement, complete, of a non-tunneled centrally inserted central venous catheter) deals with complete replacement of a non-tunneled catheter. Three other codes describe complete replacement of tunneled catheters:

36581 - Replacement, complete, of tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access

36582 - Replacement, complete, of a tunneled centrally inserted central venous catheter, with subcutaneous port, through same venous access

36583 - Replacement, complete, of a tunneled centrally inserted central venous catheter, with subcutaneous pump, through same venous access.

Two other codes address PICC line replacement. Report 36584 (Replacement, complete, of a peripherally inserted central venous access catheter [PICC], without subcutaneous port or pump, through same venous access) for procedures without a subcutaneous port or pump. Use 36585 (Replacement, complete, of a peripherally inserted central venous access device, with subcutaneous port, through same venous access) with a subcutaneous port.

With so many changes to insertion and replacement codes, it's no surprise that CPT 2004 also includes new codes for catheter removal. Again, the distinction is whether a subcutaneous port or pump is involved:

36589 - Removal of tunneled central venous catheter, without subcutaneous port or pump

36590 - Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertion.

Johnson thinks the large number of changes made to the catheterization codes may be CPT 2004's attempt to show the differences in complexity among the various line placement codes. She adds that the many changes in this category make accurate line documentation more important than ever before. Categorizing the lines so specifically might help pave the way for more anesthesia codes that correlate to the placements and also help prove that some lines are more difficult to place than others.

Look Ahead to RVG Changes

The American Society of Anesthesiologists publishes the Relative Value Guide (RVG) each year as a guide to basic values for all anesthesia procedures. Most codes and descriptors are identical to CPT codes, but sometimes there are variations. You've been able to report these non-CPT codes to some carriers and receive reimbursement. But HIPAA stipulates that you report CPT codes for procedures, which means non-CPT codes are not HIPAA-compliant.

Code 01997 (Daily hospital management of intravenous patient-controlled analgesia) is a prime example of this situation. This is an ASA code that's never been included in CPT, so it's not HIPAA-compliant. As a result, the 2004 RVG will delete 01997.