Anesthesia Coding Alert

Know line type, procedure performed, and patient age to narrow the possibilities.

When you face an op report for a peripherally inserted central catheter (PICC) service, there’s a lot you need to know. First, you must recognize that some line placements are included in the services that anesthesia providers can code — and receive reimbursement for — in addition to responsibilities included in the standard anesthesia service.

When you turn to the surgical codes in CPT^®, you’ll find numerous choices differentiated by several layers of details — which means you need to pay close attention to certain details in order to select the most appropriate code. Narrow your options for PICC line services by asking these five questions to ensure accurate selection.

Question 1: Where Are Catheter Insertion, Termination Points?

A PICC line is a catheter (long flexible tube) that accesses the central venous system via a peripheral vein. After the provider inserts the PICC line, they pass it through to the larger veins near the heart.

To qualify as a PICC line, the physician must peripherally insert the catheter, which commonly involves locations in the arm such as the basilic, brachial, cephalic, or medial cubital vein.

If the physician inserts the catheter in a central vein, such as the internal jugular, subclavian, or femoral veins, or the superior/inferior vena cava, you’re dealing with a centrally inserted central venous catheter (CVC), not a PICC line.

Important: You should have documentation that the tip of the catheter ends close to the heart or in one of the great vessels — the superior vena cava or the inferior vena cava. If that’s not the case, you’re not dealing with a PICC line, even if it’s peripherally inserted.

For instance: Midline catheters are also peripherally inserted but terminate in the peripheral venous system, so you shouldn’t report those with the PICC codes. Instead, those services are coded with 36400, 36406, or 36410 (Venipuncture … necessitating the skill of a physician or other qualified health care professional …). “As routine line placement is included in the base value for anesthesia services, these procedures are not often billed by anesthesia providers,” says Kelly D. Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida. “If the patient did not have anesthesia services and the procedure required the skill of a physician or QHP [qualified health care professional], ensure the procedure and medical necessity are clearly documented,” she adds.

If the veins documented in the op report fit the bill, move on to question two, which will bring you one step closer to identifying the correct PICC code.

Question 2: Did the Provider Tunnel the Catheter?

When you’re reviewing the op note, also check for mention of the catheter being “tunneled” — a technique in which the physician places the catheter under the skin between the vein entry and external access sites to help keep it in place.

“PICCs are not tunneled, so if you see documentation of a ‘tunneled PICC,’ this generally refers to placement of a catheter in a central vein like the internal jugular. For coding purposes, that would be considered a tunneled central venous catheter, according to the Society of Interventional Radiology,” says Robin Peterson, CPC, CPMA, manager of professional coding, Pinnacle Integrated Coding Solutions, LLC, in Hot Springs, Arizona.

If documentation indicates the catheter was tunneled, you’re probably coding for the anesthesia associated with the service rather than the catheter placement.

“The surgeon often tunnels the catheter, and we provide anesthesia, when necessary,” Dennis notes. “In that case, the anesthesia crosswalk code will depend on whether the surgeon performed a placement or repair,” she explains.

Don’t miss: The 2023 CPT^® code book has a Central Venous Access Procedures Table that provides a quick way to choose the surgical code for crosswalking to the anesthesia service (see page 297).

For anesthesia provided for catheter placement performed by a surgeon, report 00532 (Anesthesia for access to central venous circulation). For anesthesia provided for a repair, performed by a surgeon, report 00400 (Anesthesia for procedures on the integumentary system on the extremities …) (www.perfectofficesolutions.com/uploads/3/4/4/8/34488961/2009cvp_anes.pdf).

Question 3: What Was the Exact Service?

Once you’ve established that your case is a PICC line, you can break down your code search based on which of the following services the physician provides:

• Insertion: For PICC line placement, choose from the codes in range 36568-36571 (Insertion of peripherally inserted central venous catheter …).
• Repair: For repair of a PICC or CVC line, report 36575 or 36576 (Repair of central venous access device … central or peripheral insertion site).
• Replacement: For replacement of only the catheter, use 36578 (Replacement, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site). For complete replacement, report 36584 or 36585 (Replacement, complete, of a peripherally inserted central venous catheter …).

Although CPT^® provides two codes for the removal of central venous access devices (36589-36590 (Removal of tunneled central venous ...)), you shouldn’t use these codes for a PICC line.

Here’s why: These removal codes describe tunneled CVC removal and a note following the codes states, “Do not report 36589 or 36590 for removal of non-tunneled central venous catheters.” Since PICC lines aren’t tunneled, these codes don’t apply to PICC line removal.

It doesn’t take much searching to realize that CPT^® doesn’t provide a removal code for PICC lines. This is because “PICC lines are intended to be more short term than a central line, so removal is included as part of a procedure follow-up visit or as part of an E/M [evaluation and management] service performed on that date,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, California.

Question 4: Does the Note Document Pump or Port?