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Anesthesia Coding Alert

Line Coding Know-How:

Learn the Ins and Outs of A-Lines to Achieve Accuracy

Published on Mon Nov 05, 2007

Documentation helps direct whether you bill separately

You can usually code invasive line placement and monitoring separately from the procedure's anesthesia, but all lines aren't created equal. Get up to speed on when -- and how -- to correctly report arterial lines and boost your accuracy before coding your next multi-line case.


Watch for A-Lines With Trauma Patients

Physicians use arterial lines (commonly called A-lines) to measure the patient's blood pressure and to provide easier access for drawing blood to study bloodstream gases. This helps the anesthesiologist evaluate how well the patient's lungs are working by how well they move oxygen into the bloodstream and remove carbon dioxide. The line also provides a reliable method to frequently check arterial blood samples so the anesthesiologist can respond appropriately.

Who needs them: Unstable patients who are having surgery because of trauma often need A-lines. So do patients undergoing cardiac, vascular, chest, spine or brain surgery because these patients are subject to rapid blood pressure changes, according to the American Society of Anesthesiologists' (ASA) statement on invasive monitoring procedures.


Opt for 36620 More Often Than 36625

The primary code for A-line placement is 36620 (Arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; percutaneous).

Code 36625 (... cutdown) also applies to A-line placement, but you'll rarely report it because anesthesiologists normally use the percutaneous approach instead of cutdown, says Barbara J. Johnson, CPC, MPC, owner of Real Code Inc. in Moreno Valley, Calif.

On the rare occasions that require cutdown placement because the anesthesiologist is unable to locate the patient's artery through the skin, the physician creates an incision and inserts the catheter under direct vision. The anesthesiologist might not have credentials to perform this open procedure, so the surgeon performs and codes for it instead. In this case, you won't report the procedure because your physician is only monitoring the line rather than placing it, and monitoring is part of the global anesthesia fee.

To bill or not: The biggest question many coders have regarding A-line insertion is whether to report the service separately or include it with the global anesthesia fee. The answer, experts say, depends on when your physician places the line.

"We follow the line of thinking that we charge for placement if the patient has been induced," Johnson says. "This requires monitoring of the patient while the anesthesiologist is placing the line."


Verify That Documentation Meets Guidelines

Coders rarely have problems gaining separate reimbursement for any arterial lines they do report, if the physician clearly documents their placement. Expect to receive payment for three base units for 36620 or five base units in the rare instance you report 36625.

Note: Some carriers pay a flat fee for A-line placement rather than calculating reimbursement by base units. Knowing your carriers' policies will help you know how to submit the claims correctly and what reimbursement to expect.

The time factor: Because inserting an A-line is a surgical procedure rather than an anesthesia service, you don't report the time associated with placement. If you bill 36620 with time units, the carrier could interpret that as billing for anesthesia during the line insertion rather than actually inserting the line.

Check the modifier: When reporting A-lines, some carriers require modifier 59 (Distinct procedural service) appended to 36620 (or 36625) to separate the line placement from the procedure's anesthesia service. Blue Shield of Michigan, for example, used to request modifier 59 with lines, says Kelly Dennis, CPC, ACS-P, PMCC, owner of Perfect Office Solutions in Leesburg, Fla. Other carriers consider A-lines to be modifier-exempt, so verify which way you should report them.


Know Your Medical Direction and Line Policies

Many carriers (such as Palmetto GBA and Trailblazer) allow anesthesiologists to place monitoring lines while medically directing other cases, but other carriers do not make specific exceptions for the service.

What this means: Check the carrier's policy on "allowable" services during medical direction before automatically coding line placements.

Whether the anesthesiologist is involved in medically directing cases or not, he should still thoroughly document everything related to line placements so you can code them correctly. Experts recommend that you check these line-placement details in order to submit correct claims:

  • who placed the line (the anesthesiologist or another qualified anesthetist)
  • what type of line he placed
  • when he placed the line (before or after induction, and the time associated with it)
  • where he placed the line (radial or femoral for A-lines or CVPs, jugular or subclavian for PA catheters)
  • the needle size
  • complications encountered (such as multiple attempts to place lines, hematomas for A-line insertions, inadequate circulation after radial artery line placement)
  • a diagnosis that supports the line's use (because you report the line insertion as a surgical, flat-fee service).

Final checkpoint: Some experts also recommend verifying that the physician was physically present during the line insertion instead of simply checking on the case before you code the line placement.

Watch your reimbursement: Many bundling issues apply to line insertions, so check your carriers' guidelines to stay up-to-speed with their positions on multiple billings -- and to ensure you report lines correctly and receive proper reimbursement.

"Some carriers apply a multiple-surgery reduction and reduce payment to 50 percent or less of the expected allowable," Dennis says. "If you're non-contracted with the insurance company or if your contract does not indicate a reduction, you should appeal the underpayment." q

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