Anesthesia Coding Alert

Digging for details helps you cull through the choices.

Line placement is one of the services you can often report in addition to anesthesia codes, which means you should be familiar with the ins and outs of line coding. Read on for answers to the most important questions you need to ask yourself every time.

Starting point: CPT^® includes numerous codes for central venous catheter insertion (36555-36571), which gives you a wealth of choices to search through. Our experts' tips will help you narrow those choices to the most appropriate options.

Tip 1: Expect CVP With Vascular Cases

Anesthesiologists use central venous pressure (or CVP) lines during many abdominal, cardiothoracic, or other extensive vascular cases. The anesthesiologist normally inserts a CVP line for one of three reasons:

• To measure central venous pressure via the patient's superior vena cava and to monitor (and possibly adjust) the patient's blood volume (such as during a renal transplant case to ensure adequate hydration for the transplanted kidney)
• To gain IV access when peripheral IVs of adequate size are not available
• For central drug infusion during procedures that are more effective or dangerous to give peripherally (such as IV hyperalimentation, calcium chloride, concentrated potassium, Dopamine, or neosynephrine).

Using CVP lines allows the anesthesiologist to directly administer medications into central circulation for the best effect.

"In many cases, the anesthesiologist will place a non-tunneled catheter and the surgeon will place the tunneled," says Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I,  owner of Perfect Office Solutions in Leesburg, Fla. "That means you'll report the non-tunneled codes."

Here's why: Anesthesiologists tend to insert temporary CVPlines to use for monitoring during the surgical case. A surgeon usually tunnels longer-term CVPs to prevent infection, such as those used for months of chemotherapy treatment. As an anesthesia coder, you'll choose between the two non-tunneled CVP line codes:

• 36555 -- Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age
• 36556 -- ... age 5 years or older.

Tip 2: Check the Access Points and Number of Lines

Anesthesia providers usually insert a single catheter with a tunneled CVA (central venous access) device. There are times, however, when the situation requires two catheters with two different access sites (also known as a Tesio catheter). In that case, you have two code choices:

• 36565 – Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters via 2 separate venous access sites; without subcutaneous port or pump (e.g., Tesio type catheter)
• 36566 – ... with subcutaneous port(s).

Note: Using two catheters is more common for dialysis; when an anesthesiologist places two lines it's usually because he or she is increasing access, not because the multiple catheters are required. When you see two lines documented in your anesthesiologist's notes, verify whether they were used for better access during the procedure or whether they were required so you can code correctly.

Sometimes the anesthesiologist uses more than one type of line for different purposes, such as a CVP line and Swan-Ganz catheter. This can change your coding again, partly based on how the anesthesiologist completed the procedure.

Scenario 1:  If a physician places a Swan-Ganz catheter, he places it through an introducer placed in a central vein. Access to a central vein is a component of Swan-Ganz placement. The anesthesiologist obtains central venous access, then threads the Swan-Ganz through the vein for final placement in the pulmonary artery. The central venous access is used as an intermediate step in establishing the Swan-Ganz. Therefore, you report the Swan-Ganz line with 93503 (Insertion and placement of flow directed catheter [e.g., Swan- Ganz] for monitoring purposes) but not the central venous line.

Scenario 2: In some situations, the anesthesiologist might place a second CVP line for additional monitoring during the procedure. Many heart cases include two lines that the anesthesiologist inserts through separate incisions. Documenting separate sites establishes the placements are two distinct procedures, and you may bill them separately. Append modifier 59 to the CVP line code to ensure the payer doesn't consider the line placement part of the Swan-Ganz. Anesthesiologists sometimes use ultrasound guidance when placing CVP lines. Nothing in CPT^® prohibits you from reporting +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]) for vein localization for Swan-Ganz placement.

The key: You must provide sufficient documentation of permanent recording and reporting before using +76937. If the equipment cannot generate an ultrasound record, do not report +76937.

Tip 3: Know the Patient's Age

CPT^® distinguishes most of the CVA codes by the patient's age: as "under 5" and "age 5 years or older" categories. Because of this, you can automatically eliminate almost half your code choices simply by knowing the patient's age.

• For patients under age 5, your code choices are 36555, 36557, 36560, 36568 and 36570.
• For patients 5 years old or older, choose from codes 36556, 36558, 36561, 36569 and 36571.

One exception: One venous access code, 36563 (Insertion of tunneled centrally inserted central venous access device with subcutaneous pump) does not designate the patient's age.

"That means you should not rule out reporting 36563 based on the patient's age," Dennis explains. "36563 is the only CPT^® code for those circumstances, so you report it when it applies to the situation no matter the patient's age."

Tip 4: Watch for Central/Peripheral and Tunneled/Non-tunneled Insertion

Next, check your provider's documentation to determine whether the surgeon inserted the access device centrally or peripherally. To do this, you must know exactly which vessel the venous access device accesses.

A centrally inserted device usually enters the jugular, subclavian or femoral vein. A peripherally inserted device (often identified as a PICC line in surgeon documentation), in contrast, accesses the central venous system via a peripheral vein, says Gary W. Barone, MD, associate professor of surgery at the University of Arkansas for Medical Sciences in Little Rock.

• Central choices:  Again, the process of elimination allows you to narrow your code selection. For a centrally inserted access device, choose among 36555, 36556, 36557, 36558, 36560, 36561, 36563, 36565, and 36566. Once you factor in the patient's age, the list narrows even further.
• Peripheral choices: For a peripherally inserted device, your options are 36568, 36569, 36570, and 36571.

Once you know the access point, look for whether the anesthesiologist tunneled the catheter under the skin or left it exposed. "Tunneling" describes a technique in which the physician places a long catheter under the skin between the vein entry and external access sites.

Explanation: The external site where the catheter leaves the patient is several centimeters away from where the catheter enters the vein. Tunneling a catheter makes it more difficult for bacteria migrating along the catheter from the skin to reach the blood stream.

• Codes for tunneled catheters include 36557, 36558, 36560, 36561, 36563, 36565 and 36566.
• For non-tunneled catheters, your choices include 36555, 36556, 36568, 36569, 36570 and 36571.

Example: The physician inserts a tunneled CVA devicewith a single access site into the jugular vein of a 4-year-old patient. Because the device has one access point, you can rule out a Tesio-type catheter (36565, 36566). You'll eliminate other possibilities because the patient is under age 5 and because you're reporting a centrally inserted device. This leaves you to select from codes 36555, 36557, 36560 and 36563. The tunneled catheter further narrows your code choices to 36557 and36563.

Also note: You'll handle coding differently if the surgeon tunnels the catheter and your provider handles anesthesia for the tunneling. In that case, the correct anesthesia code depends on whether the surgeon completed a placement or repair:

• 00532 ((Anesthesia for access to central venous circulation) for catheter placement
• 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified) for repair.

Tip 5: Verify Whether There Is a Pump and/or Port

The final step in deciding the correct CVA code is verifying whether the access device includes a subcutaneous port and/or pump for injecting and/or administering medication directly into the vein.

• Codes describing venous access devices without a pump or port include 36555, 36556, 36557, 36558, 36565 and 36568.
• For a venous access device with either a pump or port, your choices are 36570 and 36571.
• Codes 36560, 36561 and 36566 describe procedures with a port only, while 36563 describes a procedure with a pump only.

Example: Returning to our previous example, a review of the documentation shows that the access device does not include a subcutaneous port or pump. Therefore, the appropriate code in this case is 36557 (Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; younger than 5 years of age).

Tip 6: Remember Your Modifiers

Because line placements are normally performed in conjunction with other anesthesia-related services, you may need to distinguish the services on the claim.

Here's how: Append modifier 59 (Distinct procedural service) to the appropriate line placement code.

Example: "Some carriers require a 59 modifier appended to the CVP code and some carriers won't pay with modifier 59," Dennis says. "But the majority of carriers pay for CVP procedures separate from anesthesia."

Limits: Some payers will limit payment by considering the CVP line and anesthesia service "multiple procedures" and only pay half the expected amount for line placement. Watch for these types of limitations when negotiating contracts, Dennis advises.