Anesthesia Coding Alert

In the past, partially implanted venous access devices (VAD) were coded as central venous catheters (36488* 36491*). But with the coding modifications now in effect, partially implanted VADs are coded the same as completely implanted VADs (36533, insertion of implantable venous access port, with or without subcutaneous reservoir).

Some new guidelines for coding different devices such as Hickman, PortaCath and Broviac catheters were announced earlier in 1999, and still arent necessarily understood by coders, according to Earl Adair, practice administrator at Holston Anesthesia Group, a physician practice in Kingsport, TN.

Three Categories of VAD

Three types of devices are recognized by CPT:

1. Completely implanted VADs: These are completely subcutaneous (that is, no part of the device protrudes from the skin after insertion).

2. Partially implanted VADs: These include an internal (subcutaneous) portion and an external portion that protrudes from the patients body.

3. Central venous catheters: These may be inserted by using one of several different approaches (subclavian, femoral, internal jugular, etc.). To insert the catheter, an incision is made in the skin, then a short subcutaneous tract is dilated and the catheter is passed through the tract into the vein below. The catheter is inserted through the vein until it reaches the subclavian, brachiocephalic, innominate or iliac vein, or the junction of one of these veins with the superior or inferior vena cava. If the catheter does not reach one of these vessels, it does not qualify as a central catheter.

Central Venous or Partially Implanted?

Many coders get confused about whether to code as a partially implanted VAD or a central venous catheter because at first glance theyre very similar, says Robin Flaugher, a coding specialist at Michiana Anesthesia Care, PC, an anesthesiology practice in South Bend, IN. The main thing to look for is whether a separate skin tunnel is created for the catheter to be placed.

When a central venous catheter is placed (CPT codes 36488*-36491*), a short tunnel, or tract, is created from the skin entry site to where the catheter enters the vein, says Flaugher. When a partially implanted catheter is inserted, creating the tunnel for the catheter is a specific and separate surgical step, not just making a skin incision with tract dilation. The tunnel has to be created before the catheter can be passed through.

The tunnel for a partially implanted VAD is also usually longer than that for a central venous catheter. For example, a typical skin tunnel for a partially implanted VAD can reach from the subclavicular area to below the level of the nipple.

Coding It Correctly

Payment for a partially implanted VAD may vary greatly, depending on how it is coded. Optimal reimbursement is obtained by using the implanted code 36533 (insertion of implantable venous access port, with or without subcutaneous reservoir), instead of the lower-paying central venous catheter code, 36489 (temporary placement of central venous catheter; percutaneous, over age 2). For procedures performed in a facility, Medicare assigns a total of 10.25 relative value units (RVUs) for code 36533 and 2.38 RVUs for code 36489.

Using the same code for a partially implanted VAD as for a completely implanted one is more accurate than coding it as a central venous catheter, says Flaugher. And since the difference in reimbursement is so substantial, coders should be sure that the partially implanted ones are appropriately documented and reimbursed.

However, she also points out that carriers will still reimburse for procedures that are coded as a central venous catheter instead of with code 36533. Its not the most accurate code to use, but it hasnt been denied, she says. Weve had a few claims slip through with the old code and have just been reimbursed at the lower rate.

The key to coding the procedure correctly lies with the anesthesia provider, says Adair. It can be like pulling teeth, but your best bet is to have the doctors code the work themselves, he says. Theyre the ones who are actually doing the work and are in a much better situation to know which code to use. If the anesthesiologist doesnt provide you with the information, I usually recommend that you get the patients complete medical record to use for coding purposes.

Relying on the physician for coding information brings up the issue of proper documentation of the procedure. A procedure must be coded based on its documentation, whatever that may be. Even if a catheter is partially implanted but is documented as central venous, the lower-rate central venous placement is what must be coded and filed for reimbursement.

Its really in the anesthesia professionals best interest to pay attention to the differences between codes and document it correctly, Flaugher says. If you have any questions about which type of VAD it should be coded as, check with the doctor or refer to the February 1999 issue of the CPT Assistant Coding Answer Book. There was an article in that issue that can help you distinguish between the different types.