Anesthesia Coding Alert

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

Although the global anesthesia code includes fees for most services, you can often bill separately for line placements. If your anesthesiologist frequently establishes central venous or pulmonary artery catheters, follow our experts' advice on when to separately code the lines--and when you can only report one of them.

Look for CVPs With Extensive Vascular Cases

The anesthesiologist monitors central venous pressure by inserting a central venous pressure (CVP) line into the patient's superior vena cava. Your physician also uses the line to gain IV access and monitor--and possibly adjust--the patient's blood volume. Or the physician may use a

CVP for central drug infusion during procedures that usually include fluid shifts (such as during a renal transplant case to ensure adequate hydration for the transplanted kidney).

Many abdominal, cardiothoracic or other extensive vascular cases generally include CVP line placement. Using CVP lines allows the anesthesiologist to directly administer medications into central circulation for the best effect, says Barbara J. Johnson, CPC, MPC, owner of Real Code Inc. in Moreno Valley, Calif.

Narrow Your CVP Coding Options

Years ago, CPT listed only two CVP codes. CPT 2004 changed that, however, with its complete revamping of all line placement and removal codes. Now several codes apply to CVP lines, based on the type of device your physician uses, the patient's age, and the placement technique:

• 36555-36556--Insertion of non-tunneled centrally inserted central venous catheter ...

• 36557-36558--Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump ...

• 36560-36561--Insertion of tunneled centrally inserted central venous access device, with subcutaneous port ...

• 36563--Insertion of tunneled centrally inserted central venous access device with subcutaneous pump

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

• 36568-36569--Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump ...

• 36570-36571--Insertion of peripherally inserted central venous access device, with subcutaneous port ...

Common choices: Even with so many codes to choose from, Johnson says, you probably find yourself returning to the same ones, depending on your physicians' typical services.

"This is true," says Kelly Dennis, CPC, ACS-P, PMCC, owner of Perfect Office Solutions in Leesburg, Fla. "In many cases, the anesthesiologist will place a non-tunneled catheter and the surgeon will place the tunneled--which means you'll report the non-tunneled codes."

Explanation: Anesthesiologists tend to insert temporary CVP lines that will be removed during the perioperative period. A surgeon usually tunnels longer-term CVPs to prevent infection, such as those used for months of chemotherapy treatment.

Companion codes for CVP line placement describe line repair (36575-36576), replacement (36578-36585) and removal (36589-36590).

Checkpoint: As with arterial lines (normally reported with 36620, Arterial catheterization or cannulation for sampling, monitoring or transfusion [separate procedure]; percutaneous), many carriers consider CVP lines to be modifier-exempt (meaning you can't report the lines separately, even with a modifier). Check your local guidelines before reporting CVP lines separately.

Note: For more on coding for arterial line placements, see "Learn the Ins and Outs of A-Lines to Achieve Accuracy" in Volume 9, Number 12 of Anesthesia & Pain Management Coding Alert.

Focus on PA Catheters During Heart Procedures

Placing a pulmonary artery catheter (also known as a PA catheter or a Swan-Ganz) is another type of invasive monitoring that anesthesiologists use. This catheter can monitor the functions of both sides of the heart and vasculature, plus measure cardiac output and other cardiovascular functions.

Anesthesiologists use PA catheters for patients whose cardiac function is--or might be--compromised prior to or during surgery, such as with patients whose heart fluid status needs monitoring. Monitoring the patient with a PA catheter and/or TEE (transesophageal echocardiography, 93312-93318) may help the anesthesiologist maximize the patient's cardiac function while optimizing fluid status.

Some types of PA catheters also allow the physician to temporarily pace the heart, which may be necessary for patients with underlying cardiac rhythm disturbances. Others allow the physician to continually monitor cardiac output and/or monitor mixed venous oxygen saturation.

Use Caution When Submitting TEE With PA Cath

Your physician has several types of pulmonary artery catheters to select from, but he places them all the same way and CPT covers all types with a single code. Report any PA catheter insertion with 93503 (Insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes).

TEE tip-off: If your anesthesiologist opts to use TEE for additional monitoring, also report that code--but know that carriers don't reimburse the anesthesiologist for TEE service if he only uses it for monitoring (93318, Echocardiography, transesophageal [TEE] for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing [continuous] assessment of [dynamically changing] cardiac pumping function and to therapeutic measures on an immediate time basis).

Payable TEE: Although payers won't reimburse for TEE when your anesthesiologist only uses it for monitoring, they will reimburse for diagnostic or therapeutic TEE usage. If your physician is credentialed to provide these services, report the appropriate code from 93312-93314 (Echocardiography, transesophageal, real time with image documentation [2D] [with or without M-mode recording] ...) or 93315-93317 (Transesophageal echocardiography for congenital cardiac anomalies ...).