General Surgery Coding Alert

New options replace 49420 for tunneled catheter.

Choosing an intraperitoneal catheter insertion used to mean deciding between "permanent" and "temporary" -- but CPT 2011 changes all that. Now you'll need to know if the procedure is open, laparoscopic, or percutaneous in order to choose the proper code.

Follow our experts' four tips to capture all the pay you deserve by properly maneuvering the following new and revised codes for intraperitoneal catheters:

• 49324 (revised) -- Laparoscopy, surgical; with insertion of tunneled intraperitoneal catheter

• 49418 (new) -- Insertion of tunneled intraperitoneal catheter (e.g., dialysis, intraperitoneal chemotherapy instillation, management of ascites), complete procedure, including imaging guidance, catheter placement, contrast injection when performed, and radiological supervision and interpretation, percutaneous

• 49419 (revised) -- Insertion of tunneled intraperitoneal catheter, with subcutaneous port (i.e., totally implantable)

• 49421 (revised) -- Insertion of tunneled intraperitoneal catheter for dialysis, open

• 49422 (revised) -- Removal of tunneled intraperitoneal catheter.

1. Drop 'Permanent' for 'Tunneled'

CPT 2011 gives a facelift to coding for intraperitoneal catheters used for purposes such as chemotherapy or dialysis.

"The new coding disbands the distinction between 'permanent' and 'temporary' intraperitoneal catheters," explains Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

CPT 2011 deletes 49420 (Insertion of intraperitoneal cannula or catheter for drainage or dialysis; temporary) and revises 49421 from its 2010 definition (... permanent). The 2011 codes also drop the word "permanent" from 49324, 49419, and 49422.

"These changes are helpful, because the distinction between 'permanent' and 'temporary' was not clear in practice," says John F. Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop and Associates.

Update terminology: The revised codes also drop the word "cannula" from the definitions, because surgeons commonly perform these procedures with catheters only, according to CPT Changes 2011 -- An Insider's View.

CPT 2011 adds the term "tunneled" to describe the catheters.

Tunneling describes a technique in which the physician places a long catheter under the skin between the vein entry and external access sites. The catheter may have a subcutaneous cuff to help secure it in the tunnel.

"Tunneled catheters for chemotherapy or dialysis are common, because the physician typically intends to use the catheter for a prolonged period, and tunneling makes it more difficult for bacteria to migrate along the catheter to the blood stream," Bucknam explains.

2. Choose Catheter Insertion by Approach

Since you no longer choose the correct intraperitoneal catheter code based on the permanent/temporary distinction, what is the basis for choosing the correct code?

"CPT 2011 distinguishes the codes based on whether the surgeon performs the procedure percutaneously, laparoscopically, or via an open approach, which makes much more sense," Bishop says.

Use 49324 for a laparoscopic procedure, 49418 for a percutaneous service, and 49421 for an open insertion.

3. Capture Port and Removal

If your surgeon inserts a tunneled intraperitoneal catheter with a subcutaneous port, you should report 49419 instead of one of the other codes. Look for terms such as "totally implantable" to describe the type of catheter that involves a port. You're likely to see this sort of procedure for administration of chemotherapeutic agents.

Gain removal pay: CPT also provides a code for times when your surgeon removes a tunneled intraperitoneal catheter -- 49422. Don't use this code for removing a non-tunneled catheter -- use an appropriate E/M code instead, according to CPT instruction.

"If the surgeon replaces an existing tunneled catheter, you should not report 49422 in addition to the insertion code," Bucknam says. "Report only the insertion code when the surgeon removes a tunneled catheter at the same operative session as placing a new one."

4. Don't Unbundle Image Guidance

Based on the code definitions, new codes 49412 and 49418 include image guidance, if performed. The restriction in the definition correlates to CCI edits that bundle the codes with imaging guidance by the following methods:

fluoroscopy (such as 76000, Fluoroscopy[separate procedure], up to 1 hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy])

ultrasound (such as 76942, Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation)

computed tomography (such as 77012, Computed tomography guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], radiologic supervision and interpretation)

magnetic resonance (such as 77021, Magnetic resonance guidance for needle placement[e.g., for biopsy, needle aspiration, injection or placement of localization device], radiologic supervision and interpretation).

Although revised code 49324 doesn't specifically state that it includes imaging guidance, CCI includes similar edit pairs that bundle imaging guidance with the laparoscopic catheter insertion code.

5. Use Different Codes for Drainage

Deleted code 49420 provided a way for you to report insertion of a temporary catheter for drainage. Now that the remaining intraperitoneal catheter insertion codes describe tunneled catheters for chemotherapy or dialysis, how should you report drainage?

Do this: A CPT text note following 49419 instructs, "To report open or percutaneous peritoneal drainage, see 49060, 49061, 49062, 49080, 49081, as appropriate."