Anesthesia Coding Alert

Question: I am coding a case for a patient with breast cancer (C50.912, C77.3) who received a Mediport. It is listed as a "Left cephalic vein Mediport placement/C-arm." I am having difficulty finding the appropriate CPT^® and anesthesia codes for this procedure. What do you recommend?

Wisconsin Subscriber

Answer: The code you submit will depend on the service your anesthesiologist provided. If he or she placed the Mediport, report placement code 36561 (Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older). If he or she provided anesthesia while the surgeon placed the Mediport, report the anesthesia crosswalk code instead: 00532 (Anesthesia for access to central venous circulation).

In either situation, include both diagnoses that you mention: C50.912 (Malignant neoplasm of unspecifiedsite of left female breast) and C77.3 (Secondary and unspecified malignant neoplasm of pectoral lymph nodes).