Anesthesia Coding Alert

Drill down to the details for easy code selection.

Coding for vascular access can be complicated by varied and superfluous terminology and the wealth of coding choices you must weed through — CPT^® includes 15 codes for central venous catheter (CVC) insertion (36555-36573).

In Anesthesia Coding Alert volume 26, number 7, we provided some pro tips to help you narrow your options to the correct code. In this issue, we’ll help you clear up any lingering confusion by offering more helpful hints to ensure your central line reporting is on point.

Verify Catheter Insertion, Termination Points

By definition, a central catheter is a venous access device that ultimately terminates in or near a large vein that leads into the heart, usually the superior vena cava (SVC) or right atrium (RA). Providers can insert a single, double, or triple-lumen catheter centrally (centrally inserted central venous catheter (CICC)) or peripherally (peripherally inserted central catheter (PICC)). To differentiate between central venous access devices (CVADs), you must know exactly which vessel the catheter/device enters.

A PICC is placed in a peripheral arm vein — basilic, brachial, cephalic, or medial cubital vein of the arm — and terminates in the thorax. They give the doctor access to the large central veins near the heart and can be used for medium-term venous access, which is defined as anywhere between several weeks to six months.

A CICC is inserted into a vein in the neck, chest, or groin — usually the internal jugular, subclavian, or femoral vein — and guided through one or more veins until the tip reaches the large vein that empties into the heart (vena cava).

• Central choices: For centrally inserted CVADs, choose among 36555-36566 (Insertion of non-tunneled/tunneled centrally inserted central venous …).
• Peripheral choices: For peripherally inserted CVADs, your options are 36568-36573 (Insertion of peripherally inserted central venous …).

Important: You must have documentation that the tip of the catheter terminates in the subclavian, brachiocephalic (innominate) or iliac veins, the superior or inferior vena cava, or the right atrium. If that’s not the case, you’re not dealing with a CVAD, per CPT^® guidelines.

Check for Catheter Tunneling

Once you determine central or peripheral insertion, verify whether the anesthesiologist tunneled the catheter under the skin or left the terminal end of the catheter exposed (non-tunneled). Typically, anesthesia providers place temporary, non-tunneled central lines for monitoring during the surgical case.

Surgeons usually tunnel the CVC when long-term IV access is needed. Tunneling describes a technique where the physician places the long catheter subcutaneously between the external access and vein entry sites. The external site where the catheter leaves the patient is several centimeters away from where the catheter enters the vein.

Advantage: Tunneling the catheter offers better protection against bacteria migrating along the catheter from the skin to reach the bloodstream.

• Codes for tunneled catheters include 36557, 36558, 36560, 36561, 36563, 36565, and 36566.
• For non-tunneled catheters, your choices include 36555, 36556, 36568, 36569, 36572, and 36573.

Take 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:

• Placement: 00532 (Anesthesia for access to central venous circulation); base unit value of four
• Repair: 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified); base unit value of three

Know the Patient’s Age

CPT^® distinguishes most of the CVAD 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 how old the patient is.

• 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.

Exception: One CVAD 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,” says Kelly Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida. “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,” she explains.

Investigate Whether CVAD Included a Pump or Port

The final step in deciding the correct CVAD code is verifying whether the central line includes a subcutaneous port or pump, which allows for the delivery of chemotherapy treatment, blood transfusions, antibiotics, intravenous (IV) fluids, or blood samples for testing, over a long period of time.

• Codes describing venous access devices without a pump or port include 36555, 36556, 36557, 36558, 36565, and 36568.
• For a peripherally inserted CVAD with a subcutaneous port, your choices are 36570 and 36571.

Codes 36560, 36561, and 36566 describe tunneled centrally inserted CVADs with a subcutaneous port(s), while 36563 describes central line insertion with a subcutaneous pump.

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) or one of the X{EPSU} modifiers to the appropriate line placement code, depending on payer preference. Many carriers want you to use the X{EPSU} modifiers, as they provide more information about what distinguishes the two procedures. “Medicare will only accept a 59 modifier if there is no more descriptive modifier available,” Dennis notes.

Example: “Some carriers may require an XU (Unusual non-overlapping service) modifier appended to the CVC code and some carriers won’t pay with additional modifiers,” Dennis says. “As the majority of carriers pay for CVC procedures separate from anesthesia, watch your denials and correct modifier issues you may find.”

Limits: Some payers will limit payment by considering the CVC 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.