EM Coding Alert

Question: A patient with acute respiratory failure with hypoxia is brought to the ED in a critical state. The ED physician performs critical care services totaling 85 minutes. During that time, the ED physician also performed arterial line (A-line) placement; they placed a thin catheter via guidewire into the patient’s radial artery to for continuous blood pressure monitoring and blood sampling. The A-line placement took a total of 22 minutes. Can I report the line placement separately from the critical care, and if so, which line placement code should I report?

Arizona Subscriber

Answer: You can report the critical care and arterial line placement separately; just remember to deduct the 22 minutes it took to place the line before counting the critical care minutes. This means you’ll only code for 63 minutes worth of critical care.

On the claim, report:

• 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the critical care
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99291 to show that the critical care and the line placement were significant and separate services
• 36620 (Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous) for the line placement
• J96.01 (Acute respiratory failure with hypoxia) appended to 99291 and 36620 to represent the patient’s condition

More on A-line placement: Your confusion about the code choice for the A-line placement makes sense, as there are two codes for the service. When the physician uses a Seldinger guidewire or direct catheter-over-needle technique, you’ll report 36620.

There is, however, another A-line code: 36625 (… cutdown). If percutaneous access is too challenging for the physician or it’s flat-out failed, they might employ the cutdown technique. When the physician inserts an A-line via cutdown, they will surgically expose the artery, then insert the catheter.