General Surgery Coding Alert

Coding for vascular access can be complicated by varied and superfluous terminology, while reporting the associated fluoroscopy depends on seemingly inconsistent CMS and CPT guidelines. If you understand the terminology involved and heed payers' advice, your claims submission will proceed much more smoothly. The Heart of the Matter Codes 36488-36491 describe placement of a central venous catheter (CVC or, in some cases, simply CV). Although central lines are frequently associated with a particular brand name, e.g., Triple Lumen, Quad-cath, "You cannot code on the basis of a brand name of the catheter," says Jan Rasmussen, CPC, president of Professional Coding Solutions, an Eau Claire, Wis.-based firm providing coding support, compliance review and contract coding to physicians nationwide. "Nor does the number of lumens, branches or the length of the catheter matter. Coding for central venous access is based on the age of the patient and the approach, which is either percutaneous [through the skin] or cutdown [in which cutdown is required to visualize the venous entry site]."

To insert a central line, the surgeon places the catheter and maneuvers the tip into either the inferior or superior vena cava or the right atrium. The opposite end of the catheter remains outside the body to act as a port, for instance, to supply medication and nutrients or to monitor venous pressure. Relevant codes include:
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 36489* percutaneous, over age 2 36490* cutdown, age 2 years or under 36491* cutdown, over age 2. Midline Catheters and PICC Lines 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 [...]