Anesthesia Coding Alert

Question: Can you explain how to determine whether lines placed for CABG procedures are separately billable?

Kentucky Subscriber

Answer: Coders need specific information about the lines used in coronary artery bypass graft (CABG) procedures to determine whether the insertion can be billed separately. For example, placement of arterial lines, central venous catheters (CVC), and Swan-Ganz lines can be considered separate procedures and, consequently, are billed in addition to the CABG itself if certain requirements are met.

Key: One of the most important criteria for separate billing is who placed the line. An anesthesiologist cannot bill separately for lines another physician or technician placed — even if the anesthesiologist uses the lines for monitoring purposes during the surgery. Payment is for line insertion, and monitoring these devices is part of the anesthesia fee, according to the Center for Medicare and Medicaid Services (CMS). Therefore, the anesthesia provider must clearly document that they personally placed the line(s) to bill them separately.

Also, some lines cannot be billed simultaneously, such as a CVC and Swan-Ganz, because they may be inserted through the same sheath (i.e., the CVC port might be used to thread the Swan-Ganz catheter, so only the Swan-Ganz can be billed). However, you can bill both lines if the anesthesia record clearly shows they are separate, and both are medically necessary. Indications for placement of a CVC include central drug infusion, volume replacement, or pressure monitoring.

Note: Arterial lines are commonly placed before the induction of anesthesia. When this occurs, the time spent placing the separately billable line is not counted in anesthesia time.

When lines qualify for separate billing, you may use codes such as:

• 36556 (Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older)
• 36620 (Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous)
• 93503 (Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes)

Before submitting the claim, check your payer’s requirements for separate billing of the lines. If your payer does not bundle line placements with the primary procedure, you may be able to code them separately. For those that do bundle them, use the appropriate modifier to break the edit depending on the circumstances, for example, -XP (Separate practitioner) or -XU (Unusual non-overlapping service). If your payer does not accept the X{EPSU} modifiers, append modifier 59 (Distinct procedural service) instead. If requested, provide documentation to justify the separate services.

For further study: Find more information on the proper use of X{EPSU}modifiers and -59 at www.cms.gov/files/document/mln1783722-proper-use-modifiers-59-xe-xp-xs-and-xu.pdf.