Anesthesia Coding Alert

New codes and categories improve reporting

CPT Codes 2004 includes more than 20 new central venous (CV) access codes, but you can seamlessly replace the old codes with the new - as long as you know the type of access device that the anesthesiologist inserts, the patient's age, and whether the physician used fluoroscopic or ultrasonic guidance to insert it.

Look for Centralized Codes in New Section

CPT 2004 deleted central venous catheter placement codes 36488-36491 and port-a-cath code 36533, but it added more than 20 new central venous access codes in their place. CPT's new "Central Venous Access Procedures" section centralizes all of these codes and lists them according to the type of service they describe:
 

Insertion (codes 36555-36571). Report this series when the physician places a catheter through a newly established venous access.
 

Repair (codes 36575 and 36576). Use these codes when the physician fixes the device without replacing the catheter, pump or port.
 

Partial replacement (code 36578). Look to this code when the physician replaces the catheter associated with a pump or port - not the entire device.
 

Complete replacement (codes 36580-36585). You should report a code from this series when the physician replaces the entire device through the same venous access site.
 

Removal (codes 36589 and 36590). Use these codes when the physician removes the entire device.

"Previous versions of CPT gave us very limited choices for these procedures," says Tonia Raley, CPC, claims manager for Medical Information Systems in Phoenix. "These new categories help you select the appropriate code for these procedures with regard to repair, replacement and removal."

New Groupings Aim for Precision

Another plus is that the new groupings help differentiate between catheter techniques that are quite different in terms of the risk involved and work necessary to insert them, says Scott Groudine, MD, an anesthesiologist in Albany, N.Y.

The section also includes two new codes for mechanical removal of obstructive material (36595, Mechanical removal of pericatheter obstructive material [e.g., fibrin sheath] from central venous device via separate venous access; and 36596, Mechanical removal of intraluminal [intracatheter] obstructive material from central venous device through device lumen). A code for other central venous access procedures (36597, Repositioning of previously placed central venous catheter under fluoroscopic guidance) ends the section.

Confirm the Patient's Age

Keep these tips in mind when you're searching for the perfect catheter code.
 

Many of the codes are distinguished by the patient's age, which helps narrow your choices.
 

CPT arranges the subsections according to the type of catheter that the physician uses: non-tunneled and tunneled centrally inserted central venous catheter, tunneled centrally inserted central venous access device (with and without subcutaneous pump and/or port), and peripherally inserted central venous catheter (PICC) with and without subcutaneous pump or port.
 

CPT 2004 changes some descriptors to read, "insertion of non-tunneled centrally inserted central venous catheter" instead of the old descriptor, which read, "for percutaneous access." This year, CPT states, "There is no coding distinction between venous access achieved percutaneously versus by cutdown or based on catheter size."

The Common Codes

Even with all these coding options, you'll probably find yourself using a few codes more often than the others. Some that you'll probably report most frequently include:
 

36555 - Insertion of non-tunneled centrally inserted central venous catheter; under 5 years of age

36556 - ... age 5 years or older. "This will be the most common CVP code used by anesthesiologists," Groudine says.

36568 - Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; under 5 years of age

36569 - ... age 5 years or older

36580 - Replacement, complete, of a non-tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access. You should report this code when the physician replaces an old CVP (central venous pressure line) with a new one through the same venipuncture site. Physicians usually do this if the catheter is malfunctioning or if they suspect bacterial contamination.

36597 - Repositioning of previously placed central venous catheter under fluoroscopic guidance. 
 
Anesthesiologists occasionally reposition catheters that are in the wrong place (e.g., a subclavian catheter goes up the neck instead of down to the heart). "Repositioning the catheter under fluoroscopy can be time- consuming, so it's nice to have a new CPT code for this," Groudine says.

Pay special attention to the age parameters with codes 36555, 36556, 36568 and 36569. On the positive side, CPT changed the age parameters for these procedures from "age 2 years or under" and "over 2 years" to the new guidelines, which describe patients "under 5 years of age" and "age 5 years or older."

"The work in placing a CVP for a 2-year-old isn't that different than for a 3-year-old," Groudine says, "but the 5- year-old cutoff better differentiates the harder pediatric management from the adult management."

Refresh Your Medical Terminology Expertise

When you report the new access codes, always differentiate between tunneled and non-tunneled catheters. Raley and Groudine offer these tips about the two types:
 

Surgeons typically insert tunneled catheters such as Hickman, Broviac or Groshong. Anesthesia coders won't report tunneled catheter insertion and fluoroscopic guidance, but the surgeon sometimes requests general anesthesia for these procedures. Report this with the appropriate anesthesia code, based on the surgical service.
 

An anesthesiologist or surgeon might insert non-tunneled catheters (Hohn catheters, triple lumen catheters or PICC lines). For example, a pain management specialist might insert a non-tunneled catheter for IV opioid treatment of metastatic cancer. The physician leaves the catheter in for a longer period of time with a lower incidence of infection while the patient has ready access to IV opioids. The physician places these catheters directly into the artery without using fluoroscopic guidance.

Some anesthesiologists use acronyms when documenting catheter insertions, so you should familiarize yourself with "CVP lines" and "PICC lines." 

The physician places a central venous pressure (CVP)  catheter in the internal jugular, external jugular, femoral and subclavian vein. The CVP is a short-term device used for pressure monitoring, volume replacement or central drug infusion. By contrast, the physician uses a peripherally inserted central catheter (PICC line) for intravenous medication, chemotherapy or fluids that the patient requires long-term.

CPT Introduces 2 New Codes

In addition to changing so many catheter codes, CPT 2004 also introduced two new CVP imaging codes:
 

+75998 - Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (list separately in addition to code for primary procedure)

 +76937 - Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (list separately in addition to code for primary procedure).

"These codes acknowledge the increasing role of ultrasound in locating and safely placing CVP lines," Groudine says. "If you have documentation showing that the physician used permanent reporting and recording during the ultrasound, you may use 76937 as an add-on to the primary procedure code."