Anesthesia Coding Alert

Verify uses before filing that next claim -- or face denials.

Line placements can be some of your bottom line's best friends because you can often bill the service separately. Check out our experts' advice on when you can code for central venous catheters -- and when the anesthesia code includes line placement.

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 renaltransplant 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, explains Scott Groudine, MD, an Albany, N.Y.anesthesiologist.

Narrow Your CVP Coding Options

CPT lists quite a few codes for CVP lines, based on the type of device your physician uses, the patient's age and the placement technique. "In many cases, the anesthesiologist will place a non-tunneled catheter and the surgeon will place the tunneled," says Kelly Dennis, MBA, ACS-AN, CANPC, CPC, 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 CVP lines to use for monitoring during the surgical case, says Debbie Farmer, CPC, ACS-AN, senior compliance officer with Auditing for Compliance Education, Inc., in Leawood, Ks. 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 nontunneled 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.

Documentation Might -- or Might Not -- Justify CVP

The American Society of Anesthesiologists states that the anesthesia base units do not include CVP service, which means you can report both the anesthesia code and the CVP code, Farmer says. Some payers have specific policies regarding CPV line coding, so always know your local guidelines.

Example: "Some carriers require a 59 modifier (Distinct procedural service) 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.

Circumstances Dictate Multiple Lines

How do you handle procedures that include multiple line placements, such as a CVP line and Swan-Ganz catheter? The answer depends partly 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," explains Groudine. "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. He uses the central venous access 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.