General Surgery Coding Alert

In some cases, the surgeon may report placement of a midline catheter, or MLC, which results in less advanced placement of the catheter tip. "To report a true central line, the physician must document that the catheter tip was positioned in either the subclavian, brachiocephalic, innominate or iliac veins or at the junction of one or more of these veins with the superior or inferior vena cava," says Kathleen Mueller, RN, CPC, CCS-P, a cardiology coding and reimbursement specialist in Lenzburg, Ill. If the surgeon does not advance the tip that far, it's not a CVC, she adds. The distinction has no bearing on coding, however. "Even though the placement of the tip is a little different for a midline, both midline and the central venous catheters are reported with 36488-36491," says Rasmussen, who is also a former member of the AAPC National Advisory Board and previous AAPC liaison to the American Medical Association.

When dealing with venous access, coders are also likely to encounter peripherally inserted central catheters, or PICC lines. In this case, the surgeon places the catheter in one of the large antecubital veins and threads it into the superior vena cava above the right atrium. These may be either central or midline catheters, based on the final location of the tip. Once again, however, the terminology is irrelevant to coding: All PICC lines are reported using 36488-36491, as appropriate to the circumstances.

'Tunneled' Catheters

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," Rasmussen explains, "the catheter goes in one area and exits the skin for physician access in a different area, generally around or below the nipple." Such catheters may include a subcutaneous reservoir.

To report a tunneled CVC (or Tesio catheter), use code 36533 (Insertion of implantable venous access device, with or without subcutaneous reservoir). "Tunnel catheters are considered partially implanted, and AMA guidelines dictate that you report tunneled central lines with 36533," Rasmussen says. Bill removal of a tunneled catheter using 36535 (Removal of implantable venous access device, and/or subcutaneous reservoir) and revision of a tunneled catheter using 36534 (Revision ...). Report 36534 with caution, however: If the physician does not completely revise the catheter but only adjusts the tip (which is more common), the appropriate code is 36493 (Repositioning of previously placed central venous catheter under fluoroscopic guidance).

Note: Do not use 36488-36491 with modifier -22 (Unusual procedural services) to report implantation of a tunneled catheter. Although the AMA previously endorsed this method, it has since revised its guidelines to reflect the above information.

Physicians often use fluoroscopic guidance to aid in placement of catheters, but reporting separately for this service has become more complex in recent months.

Chapter one, section C, version 7.3 of the national Correct Coding Initiative (CCI), effective Nov. 1, 2001, included revisions that dictated, "General fluoroscopic services necessary to accomplish routine central vascular access or endoscopy cannot be separately reported unless a specific CPT code has been defined for this service." In spite of this directive, version 7.3 contained no numerical code pair edits that forbade use of 76000 (Fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) with 36488-36491 or 36533. The latest version of CCI (8.1) has not eliminated the inconsistency.

Because 76000 is a nonspecific fluoroscopy code that does not apply only to catheter placement, the CCI text suggests that it may not be separately reported (although CPT specifically directs coders to report 76000 for fluoroscopic guidance with 36493 and 36533).

However, Linda Laghab, CPC, coding manager for Pediatric Management Group at Children's Hospital Los Angeles, suggests that 76000 is appropriate with catheter placement as long as the insertion is difficult and the difficult or unusual circumstances regarding the placement are documented. "When reporting 76000, the cardiologist should document the use of fluoroscopy by including a sentence noting, for instance, 'Under fluoroscopic guidance, the catheter was positioned at the subclavian vein,' " she says. Nevertheless, she agrees that separate billing for fluoroscopy is inappropriate if it is routinely used for the placement of central lines.

Rasmussen says the Society for Cardiovascular and Interventional Radiologists recommends reporting 76003 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) for the fluoro-scopic guidance of central lines. "After all, most catheters have a needle at the beginning," she says.

In the absence of clear guidelines, you may wish to turn to your individual payers for guidance. Be sure to get recommendations in writing. In the meantime, Rasmussen advises keeping an eye on the CCI: Future versions may indeed include numerical code pair edits bundling fluoro-scopic guidance to the venous access codes.