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Cardiology Coding Alert

Catheter Tip Placement Impacts Venous Access Coding

Published on Mon Apr 01, 2002

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A cardiologist may be required to place a central line in a patient with heart failure or cardiogenic shock. The central line, also known as a central venous catheter (CVC), provides medication and fluids to a patient who cannot have a peripheral line placed or who needs medications that are more appropriately administered through a central line. To correctly report the procedure as a central line placement, the cardiologist must document the indication for the CVC placement and the catheters final destination.
 
To insert a central line, the cardiologist places the catheter percutaneously into a vein (subclavian, jugular or femoral) then maneuvers the catheter tip into either the inferior or superior vena cava, or the right atrium. The other end of the catheter is left out of the body to act as a port to supply medication and nutrients and monitor venous pressure, among other things.
 
Although central lines are frequently associated with the brand name of a particular catheter (some well-known brands are Triple Lumen and Quad-cath), the make of catheter is not a factor when reporting the procedure, notes Kathleen Mueller, RN, CPC, CCS-P, a cardiology coding and reimbursement specialist in Lenzburg, Ill. In addition, the length of the catheter and the number of catheter lumens (lines) need not be considered.
 
The code most commonly used to report central line placement is 36489* (Placement of central venous catheter [subclavian, jugular, or other vein] [e.g., for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy]; percutaneous, over age 2).
 
To correctly bill a true central line, the cardiologist must document that the catheter tip was positioned in either the superior or inferior vena cava or in the right atrium, Mueller says. The site where the catheter is inserted is not a factor, and insertions into the subclavian, femoral or any other vein are coded identically.
 
If the catheter was not advanced as far as that, a central line placement has not been performed, she adds. Nurses typically perform these placements (known as midline catheters), which are reported using 36000* (Introduction of needle or intracatheter, vein).
 
Midline catheters may be confused with peripherally inserted central catheters (known as PICC lines), which are usually placed by a nurse (when they are midline catheters) but are positioned by a cardiologist if the catheter is advanced to either vena cava or the right atrium.
 
Note: If the nurse is unable to get the IV started and the cardiologist is called in for that reason only, only 36000* should be reported. A separate E/M service should not be billed, because there is no chief complaint and the cardiologist is there simply to place the IV. If, on the other hand, an E/M service resulted in the decision to place the PICC line, the E/M service should be billed in addition to 36000*.
 
Other Coding and Payment Issues
 
Catheter Removal. CPT does not include a code for central venous catheter removal: It should not be reported separately, because 36489* covers catheter removal. If the cardiologist examines the patient and performs the components of an E/M service, however, an inpatient (or outpatient, depending on the place of service) visit may be reported.
 
Critical Care. Central line placement is not included in critical care services and may be reported separately. If a central line is placed as the cardiologist provides critical care services, report 36489* in addition to 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and, when necessary, +99292 ( each additional 30 minutes [list separately in addition to code for primary service]).
 
Modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be appended to 99291 (and +99292, if necessary). The time required to complete the procedure should be documented in the medical record and should be subtracted from the total time listed for critical care, Mueller says.
 
Fluoroscopy. CPT directs cardiologists who perform imaging guidance for 36489* to bill 76000 (Fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]), says Linda Laghab, CPC, coding manager for Pediatric Management Group at Childrens Hospital Los Angeles. When reporting 76000, the cardiologist should document the use of fluoroscopy by including a sentence to the effect that Under fluoroscopic guidance, the catheter was positioned at the subclavian vein, she says.
 
However, fluoroscopy should not be billed separately if it is used routinely for the placement of central lines.  
 
According to guidelines in Chapter One of the Correct coding initiative CCI, first published in CCI version 7.3 and effective as of Nov. 1, 2002, General fluoroscopic services necessary to accomplish routine central vascular access or endoscopy cannot be separately reported unless a specific CPT codes has been defined for this service.
 
Because 76000 is a nonspecific fluoroscopy code that does not apply only to central line placement, it may not be reported if used routinely. If, however, the insertion was difficult and fluoroscopy was used for guidance, 76000 may be reported separately as long as the difficult or unusual circumstances regarding the placement are documented.
 
Modifier -51 Exempt. Although 36489* is not an add-on code, CPT designates it as exempt from multiple-procedure guidelines, and Medicare carriers should pay at 100 percent of the fee schedule rate. Private payers may, nevertheless, reduce the fee 50 percent.

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