General Surgery Coding Alert

Question: Our surgeon performed a percutaneous arterial catheterization for a transfusion using ultrasound guidance. How should we code this?

Maine Subscriber

Answer: You should report the arterial catheterization as 36620 (Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous).

If the surgeon documents using the ultrasound (US) for real-time guidance of passing the catheter into the artery, you should additionally report the US guidance add-on code +76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure)). Use this code only when the surgeon performs both the access procedure and the US guidance.

Caveat: Even if the surgeon uses US guidance to examine multiple sites to select the best access point, you can report +76937 once per session.

Modifier: If the surgeon performs these procedures in a facility, you should append modifier 26 (Professional component) to the US guidance code. Also, ensure that surgeon has provided clear documentation interpreting the US guidance.