Anesthesia Coding Alert

Remember these tips to find central line coding success.

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. However, that’s not always an easy task.

Why? CPT^® includes numerous codes for central venous catheter (CVC) insertion (36555- 36571), differentiated by several layers of details. They require you to pay close attention to certain procedure specifics, which can assist you in selecting the most appropriate code.

Our experts’ insight and hints will help you narrow those choices to the most appropriate options the next time your anesthesiologist inserts one of these lines during surgery.

Expect CVCs With Extensive Cases

A central venous catheter, also known as a central venous line (CVL), is an important part of anesthetic monitoring for some major surgeries (heart, brain, abdominal) and is essential for certain operations.

To place a central line, the physician inserts a central venous access catheter in the neck, chest, or groin and maneuvers the tip into either the inferior or superior vena cava or the right atrium. The opposite end of the catheter remains outside the body to act as a port, for instance, to supply medication or to monitor venous pressure.

An anesthesiologist normally inserts a CVC for one of three reasons:

• To measure central venous pressure (CVP) 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; or
• For central infusion of drugs that are more effective or dangerous to give peripherally (such as IV hyperalimentation, calcium chloride, concentrated potassium, dopamine, or phenylephrine). Using central lines allows the anesthesiologist to directly administer medications into central circulation for the best effect.

Pro tip: “In many cases, the anesthesiologist will place a non-tunneled catheter and the surgeon will place the tunneled,” says Kelly Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida. That means you should expect to see a procedure report that includes documentation of final catheter position. In this case, you’ll typically report the non-tunneled codes:

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

Here’s why: Anesthesiologists tend to insert temporary central lines to use for monitoring during the surgical case. Surgeons usually tunnel the CVC when long-term IV access is needed (i.e., antibiotics, chemotherapy, parenteral nutrition, fluid resuscitation, and hemodialysis) because tunneled lines have a lower rate of infection than non-tunneled catheters.

Tally Access Points and Number of Lines

Anesthesia providers usually insert a single catheter. There are times, however, when the surgeon requires two catheters with two different access sites (also known as Tesio catheters). In that case, you can crosswalk the surgical codes to the appropriate anesthesia code:

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

These surgical codes both crosswalks to anesthesia code 00532 (Anesthesia for access to central venous circulation).

In such scenarios, anesthesia is provided for the surgeon to place tunneled catheters. You should expect to see pre- and post-anesthesia evaluations, as well as an anesthesia record with documentation of time, in the notes.

Using two catheters is more common for dialysis. Anesthesiologists might sometimes place two lines, but the second line isn’t typically required. The anesthesiologist just wants lots of access.

Result: When you see two lines documented in your anesthesiologist’s notes, verify whether they were placed to improve vascular access during the procedure and whether they required two separate sites, so you can code correctly.

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

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

Scenario 2: In some situations, the anesthesiologist might place a second CVL 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 (Distinct procedural service) (or the appropriate X{EPSU} modifier for Medicare claims) to the CVC code to ensure the payer doesn’t consider the central line placement part of the SGC.

Don’t Forget To Inquire About Imaging Guidance

Anesthesiologists sometimes use ultrasound guidance when inserting a CVC. Nothing in CPT^® prohibits you from reporting add-on code +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)) when the physician employs ultrasonography for vein localization to facilitate catheter placement.

The key: The provider must include the permanent recordings and a description of the guided access process in the final procedural report. Before using +76937, make sure you have a documented description of the process and permanent recorded image(s) of the vascular access site.

If the provider uses fluoroscopic guidance, consider including +77001 (Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure)) in addition to the primary procedure code.

Stay tuned. We’ll provide additional pro tips about line placement coding next month.