ED Coding and Reimbursement Alert

Focus on central lines to avoid CPT 2004 confusion

The slew of new CPT codes for venous access in 2004 will throw you for a loop if you're unfamiliar with the details of the procedures. But you may not need to go through that much trouble - most emergency departments perform only a few of the services regularly.

Miss the Forest for the Trees

CPT has rewritten the entire section on central venous access procedures, which now clarifies and distinguishes between insertion, repair, revision, removal and imaging. The only codes you should concentrate on, though, are two of the codes for centrally inserted central lines, says Dennis Beck, MD, FACEP, CEO of Beacon Medical Services in Colorado and chairman of the ACEP reimbursement committee.
 
Centrally placed venous access devices are located close to the great vessels, says Jim Collins, CHCC, CPC, president of Compliant MD Inc. in Matthews, N.C., as opposed to peripherally inserted devices, which will be farther away.
 
Keep your eyes on codes 36555 (Insertion of non-tunneled centrally inserted central venous catheter; under 5 years of age) and 36556 (... age 5 years or older), because they'll pop up far more often than other codes in the set. "What we do in the emergency department is a very small subset of this new family of codes. If you focus on the codes that are relevant for emergency physicians, [coding is] actually not that difficult," Beck says.
 
Confusion may arise if coders read the new codes and try to interpret which procedures the physicians are performing according to the whole code set. To nip this problem in the bud, Beck stresses the importance of "preemptive education for the coders and physicians to make sure everybody knows which codes are used." For example, ED doctors will not usually perform insertions of tunneled venous access devices, devices with subcutaneous pumps or ports, or peripherally inserted central venous catheters (PICC lines) - so don't get wrapped up in memorizing the new codes for those procedures.
 
"We do - primarily - centrally inserted central lines, and there are only two codes that describe that," Beck says. The other procedures are mostly elective rather than emergent, he says. But "if your particular hospital or group does [the rest of the procedures], then you really need to be familiar with this family of codes. But this is the rare exception, not the rule."

Start and Stop With Correct Documentation

You've only got two codes to remember, but your physician's documentation might not make reporting them easy. "Sometimes you'll see people use brand names - for example, 'A Cortis line was inserted,' " Beck says. "Well, that doesn't describe the location of the tip of the catheter." And since Cortis make both peripheral and central lines, an auditor is going to want documentation that the tip of the catheter is centrally located.
 
"The tip of the catheter has to be in the vena cava, right atrium, subclavian vein, brachiocephalic, innominate vein, or an iliac vein," Collins says, so make sure your physician notes this in the chart. And the entry site should be in the patient's jugular, subclavian, femoral, or inferior vena cava, he says.
 
Age and site of insertion should be your primary concern, so the documentation should state whether the patient is older or younger than 5, and whether the physician inserted the catheter centrally.

Don't Leave $40 of US Guidance by the Wayside

One code you'll need for these procedures isn't listed with the 36555-36597 code set, and omitting it could cost you considerable reimbursement. When the physician performs ultrasound guidance for the venous access, you should also report add-on code +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). Remember, too, that "this code does require documentation and an image, and it's not just locating the vessel - it's actually puncturing the vessel,"  Beck says. If you forget to add this code when appropriate, "that's a real missed revenue opportunity," he says. Every failure to report 76937 means another $40 you haven't received.