General Surgery Coding Alert

With 13 codes to describe placement of central venous (CV) access devices, you may stare at your CPT manual and wonder where to start -- but choosing the proper code for your surgeon's procedure doesn't have to be overwhelming. By following four steps, you're guaranteed to choose the correct CV access device placement code every time.

The first thing you need to do when choosing a CV access code is look at the type of catheter your surgeon used. Determine whether he used a tunneled catheter, a nontunneled device, or a peripherally inserted central venous catheter (PICC), says Sundae Yomes, CPC, trauma services coder at HCA Physician Services in Las Vegas.

Look to the documentation to find out whether the surgeon tunneled the catheter under the skin or left it exposed. Tunneling describes a technique in which the surgeon places a long catheter under the skin between the vein entry and external access sites.

Tip: If your surgeon places the line percutaneously for short-term use, he probably uses a nontunneled catheter (36555-36556, Insertion of non-tunneled centrally inserted central venous catheter ...). If, however, the physician intends to use the line for prolonged periods, tunneling the catheter under the skin adds a bit of work to the procedure but also makes it more difficult for bacteria to migrate along the catheter into the blood stream. The tunneled catheter insertion codes are 36557-36566 (Insertion of tunneled centrally inserted central venous catheter ...). (See the box onpage 75 for detailed descriptors of each individual CPT code.)

Caution: You should never assume whether the inserted device is tunneled or nontunneled, or with or without a subcutaneous port or pump. Your surgeon'soperative report should explicitly state what he inserted.

One access point or two? In the relatively uncommon case when the surgeon inserts a tunneled CVA device requiring two catheters with two different access sites (also known as a Tesio catheter), you can narrow your code selection to just two codes, 36565 (Insertion of tunneled centrally inserted central venous access device, requiring two catheters via two separate venous access sites; without subcutaneous port or pump [e.g., Tesio type catheter]) and 36566 (... with subcutaneous port[s]).

Physicians normally insert PICC lines through a peripheral vein and then negotiate them into the central venous circulation rather than inserting them directly into a central vein. For PICC line insertions, you'll use a code from the 36568-36571 range (Insertion of peripherally inserted central venous catheter [PICC] ...).

Keep in mind that it is fairly common for nonphysicians, such as nurses, to insert PICC lines. Frequently, in a hospital setting the by the IV therapy team inserts the PICC line, Bishop explains. You would not billfor PICC line insertions by non-physicians in the facility setting. The physician cannot bill for the PICC line insertion unless he personally places the catheter. Supervising a nurse in the hospital setting does allow billing for these services.

Important: Avoid coding catheter placement using only brand names or without complete documentation of the procedure, Yomes cautions, because surgeons may use many popular types of catheters in several different ways. As a general rule, Hickman, Broviac, Lifeport, and Groshong catheters are tunneled, while Hone and triple-lumen catheters are non-tunneled. Although these terms can provide a clue to proper coding, you should not rely on them exclusively. Likewise, if the surgeon documents placement of a Tesio-type catheter, be surethe device has two separate access sites before reporting 36565 or 36566.

Next, determine whether he surgeon used a subcutaneous port or pump during the procedure, says John F. Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop and Associates. Look at the physician's report to see whether the access device he placed includes a subcutaneous port and/or pump for injecting and/or administering medication directly into the vein.

Codes describing venous access devices without a pump or port include 36555, 36556, 36557, 36558, 36565,and 36568. For a venous access device with either a pump or port, your choices are 36570 and 36571. Codes 36560, 36561, and 36566 describe procedures with a port only,while 36563 describes a procedure with a pump only.

Keep in mind: You should report 36568-36569 (Insertion of peripherally inserted central venous catheter [PICC], without subcutaneous port or pump ...) for externally accessible PICC line insertion, and 36570-36571 for peripherally inserted central venous access devices with subcutaneous ports.

Your next step will be to read through the physician's documentation to find out if he centrally inserted or peripherally inserted the catheter. To determine this, you must know exactly which vessel the venous access device accesses.

How it works: A centrally inserted device usually enters the jugular, subclavian, or femoral vein -- or sometimes the inferior vena cava. A peripherally inserte device (or PICC line), in contrast, accesses the central venous system via the basilic or cephalic vein.

CPT establishes that central venous access catheters or devices must terminate in the subclavian, brachiocephalic (innominate), or iliac veins, the superior or inferior vena cava, or the right atrium. To be considered a central insertion, the access site (where the catheter enters the vascular system) must be in an artery close to the central circulatory system, including the jugular, subclavian, or femoral vein, or inferior vena cava.

"Coders really need to know their anatomy," Bishop says. By identifying the type of insertion you can again narrow your code selection. For a centrally inserted access device, you must choose among 36555, 36556, 36557,36558, 36560, 36561, 36563, 36565, and 36566. For a peripherally inserted device, your choices are 36568,36569, 36570, and 36571.

Ask for clarification: If you cannot find the information you need to determine the type of insertion, go back to your surgeon for clarification, Yomes says. "When in doubt, ask for help," she adds.

Your final step in choosing the proper CV access device placement code will be to look at how old the patient is. Because CPT divides most of the CVA codes into "younger than 5" and "age 5 years or older" categories, you can automatically eliminate almost half your code choices simply by knowing the patient's age.

For patients under age 5, you narrow your code choices to 36555, 36557, 36560, 36568, and 36570.

For patients 5 years old or older, you can concentrate on codes 36556, 36558, 36561, 36569, and 36571.

Exception: One CV access code, 36563, does not designate the patient's age. Because 36563 does not specify "younger than 5 years of age" or "age 5 years or older," you should not rule out this code based on the patient's age.