General Surgery Coding Alert

Scenario: A surgeon is asked to insert a Port-A-Cath for chemotherapy three weeks after a partial mastectomy with axillary node dissection was performed. The primary diagnosis was 459.89 (collateral circulation [venous], any site; phlebosclerosis; venofibrosis), while the secondary ICD-9 was 174.4 (malignant neoplasm of female breast, upper-outer quadrant).

In the scenario above, many coders often select the wrong code: Instead of 36533 (insertion of implantable venous access port, with or without subcutaneous reservoir), they sometimes code the procedure with 36488 (placement of central venous catheter [subclavian, jugular or other vein][e.g., for central venous pressure, hyperalimentation, hemodialysis or chemotherapy]; percutaneous, age 2 years or under) or 36489 (percutaneous, over age 2).

Much of the confusion stems from the fact that physicians often document the brand name of the device in the patients chart and not what procedure was actually performed, says Jacqueline Leopold, CPC, president of Practice Management Consulting Corp. in Highland Park, IL. However, knowing the catheters brand name does not necessarily help the surgeons staff file the procedure correctly.

Coders need to understand the two codes that are available, and physicians need to become more aware that, even though they know what procedure was performed, they need to communicate it more accurately to their staff and stop using the catheters brand name to indicate the procedure, Leopold, whose clients include general surgeons says.

Among the better-known brand names are Port-A-Cath, Perm Cath, Broviac, Groshong, Hickman and Tessio. But if your coder doesnt know which of these catheters are used for which procedure, it will be extremely difficult for him or her to code correctly. And many coders have never even seen a catheter.

Knowing Op Report Key Words Essential to Correct Coding

What coders need to do, says Kathleen Mueller, RN, CPC, CCS-P, a physician reimbursement specialist in the office of Allan L. Liefer, MD, a general surgeon in Chester, IL, is read through the procedure section of the operative report to find out how the catheter was inserted. Looking at the top of the report is not enough: Typically, it will say insertion of Groshong or insertion of Hickman, which is completely understandable for the surgeon but not for the coder.

Once the coder is aware of how the catheter was actually inserted into the body, he or she can proceed to bill without further difficulty.

The key word the coder should look for to distinguish between the procedures is tunneling. According to a Medicare Bulletin issued for the state of Ohio, 36533 should be used for both completely and partially implanted devices that are employed for central venous access. This applies is more states than Ohio, but not all, so check with your local carrier. The procedure involves at least two incisions and the surgical development of a subcutaneous tunnel with blunt dissection. These kinds of catheters are typically intended for long-term use, and indications include (but are not limited to) long-term venous access, chemotherapy, or other long-term therapy requiring central venous administration; and dialysis. These are not routinely placed at the bedside or by nurses. In other words, the 36533 means the incisions were made below and the catheter was tunneled under the skin through subcutaneous tissue into the vein.

The procedure outlined above differs from the short subcutaneous tract incidentally formed when placing a peripherally inserted central catheter (PICC) line or triple-lumen catheter and temporary subclavian or femoral venous lines. This procedure is coded 36489 and is typically used for ICU patients or for temporary dialysis access in patients older than two years of age.

The surgeon cleansed outside and then pierced the skin directly into the vein. These catheters are intended for short- or medium-term use.

Note: The two procedures are reimbursed at widely different rates. Code 36533 has 10.28 RVUs, while 36489, the lesser procedure, is paid out at less than a third of that, 3.13 RVUs.

If appropriate documentation is not submitted, carriers have no way of knowing which procedure was performed and may pay for the lesser on in error. Alternatively, they might indicate the claim is under pending review when they send back the Explanation of Benefits and request the operative report. What the carrier wants to see in the documentation is that he or she actually inserted a tunneling device and not a direct central line, Mueller says.

She also notes that North Carolinas Medicare carrier, for one, is telling providers to bill the procedure with a 36489 regardless of the kind of access port created, but then insisting that providers code the removal of the same access port with a 36535 (removal of implantable venous access port and/or subcutaneous reservoir), which, according to Mueller, makes no sense at all, since that code refers to removing a tunnelled access port.

Reason For Insertion Not Diagnosis

Implantable venous access ports typically are placed in patients undergoing chemotherapy or who suffer from Lymes disease or osteomyelitis. This is typically because the medication they receive can be toxic for veins and/or the patient may already have poor veins.

It is important to remember that the diagnosis code used by the surgeon should not be based on the reason why the medication is being administered. In other words, you should not use cancer or osteomyelitis as the diagnosis code for the insertion of an implantable venous access port (36533); the catheter is being inserted because the patient has weak veins. So 459.89, which indicates a diagnosis of phlesbosclerosis or venofibrosis, should be used.

The primary diagnosis (cancer, osteomyelitis) may also be included, though it is not necessary.

Mueller also notes that codes 36488-36489 sometimes will be denied because medical necessity has not been indicated. Say, for example, the surgeon performs a colon resection. If the patient is debilitated, the surgeon will insert a central venous catheter during surgery. If the ICD-9 diagnosis code accompanying the 36488-36489 describes the reason for surgery, not the reason why the catheter was inserted, the claim may be denied.

Note: If the 36533 or 36488-36489 is being performed during a primary procedures global period, modifier -79 (unrelated procedure or service by the same physician during the postoperative period) must be added, unless the procedure was planned pre-operatively, in which case modifier -58 (staged or related procedure or service by the same physician during the postoperative period) would be attached instead. Also note that according to the National Correct Coding Initiative, when code 36488-36491 is billed with 36533 they will bundled into the 36533. Only one of the codes in the pair will be allowed unless documentation is provided that indicates that the two services represent different sites or sessions; if that is the case, modifier -59 (distinct procedural service) should be used.