General Surgery Coding Alert

Pay attention to procedure description, not brand names, when identifying venous access devices

If you're trying to sort through the 13 codes that describe placement of venous access devices (36555-36571), ask yourself five questions to ensure coding success.

1. 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 and 36566, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. (see "Know the CVA Placement Codes" later in this issue for complete definitions).

If your surgeon's documentation describes a double catheter access device as defined by 36565 or 36566, skip ahead to question 5 to select the appropriate code. Otherwise, move on to question 2.

2. How Old Is the Patient?

Because CPT divides most of the CVA codes into "under 5" and "age 5 years or older" categories, you can automatically eliminate almost half your code choices simply by knowing the patient's age, Jandroep says.

For patients under age 5, you narrow your code choices to 36555, 36557, 36560, 36568 and 36570 (plus 36563, see below).

For patients 5 years old or older, you can concentrate on codes 36556, 36558, 36561, 36569 and 36571 (plus 36563, see below).

Watch for the exception: One venous access code, 36563, does not designate the patient's age. Because 36563 does not specify "under 5 years of age" or "age 5 years or older," you should not rule out this code based on the patient's age, Jandroep says.

3. Central or Peripheral Insertion?

Now, check your documentation to see if the surgeon inserted the access device centrally or peripherally. To determine this, you must know exactly which vessel the venous access device accesses.

A centrally inserted device usually enters the jugular, subclavian or femoral vein, or sometimes the inferior vena cava. A peripherally inserted device (often identified as a PICC line in surgeon documentation), in contrast, accesses the central venous system via the basilic or cephalic vein, says Gary W. Barone, MD, associate professor of surgery at the University of Arkansas for Medical Sciences in Little Rock.

Again, the process of elimination allows you to narrow your code selection. For a centrally inserted access device, you must choose among 36555, 36556, 36557, 36558, 36560, 36561, 36563, 36565 and 36566.

Remember: 36565 and 36566 describe a double catheter access device, so you should have already eliminated these choices, as well.

For a peripherally inserted device, your choices are 36568, 36569, 36570 and 36571.

Example: The surgeon inserts a central venous access device with a single access site into the jugular vein of a 4-year-old patient.

Because the device has one access point, you can rule out a Tesio-type catheter (36565, 36566). Because the patient is under age 5, you needn't consider 36556, 36558, 36561, 36569 or 36571. And because the procedure describes a centrally inserted device, you can also look past 36568, 36569 and 36570.

This leaves you to select from codes 36555, 36557, 36560 and 36563. To further narrow your selection, move on to the next question.

4. Tunneled or Not?

Next, you should determine 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

"In other words," Barone says, "the catheter goes in one area and exits the skin for physician access in a different area." These catheters may have a subcutaneous cuff to help secure them in the tunnel, he adds. If the physician intends to use the line for prolonged periods, tunneling makes it more difficult for bacteria to migrate along the catheter into the blood stream.

Codes for tunneled catheters include 36557, 36558, 36560, 36561, 36563, 36565 and 36566.

For non-tunneled catheters, your choices include 36555, 36556, 36568, 36569, 36570 and 36571.

Example: Continuing with the earlier example, we'll assume that the surgeon does, in fact, tunnel the catheter. This further narrows your code choices for this example to 36557 and 36563.

5. Is There a Pump and/or Port?

Finally, you must consider whether the access device the surgeon places includes a subcutaneous port and/or pump for injecting and/or administering medication directly into the vein, Jandroep says.

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.

Example: Returning again to our example, a review of the documentation shows that the access device does not include a subcutaneous port or pump. Therefore, the appropriate code in this case is 36557.

Bonus Tip: Beware 'Brand Names'

Avoid coding catheter placement using only brand names or without complete documentation of the procedure, because surgeons may use many popular types of catheters in several different ways.

As a general rule, Hickman, Broviac 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 sure the device has two separate access sites before reporting 36565 or 36566.