Oncology & Hematology Coding Alert

Question: Our oncologist uses central venous catheters to deliver chemotherapy. If he uses a PICC line on a 4-year-old patient, can you tell me how to code placement, checking for patency, chemotherapy injections, and removal?

Maryland Subscriber

Answer: Coding central venous catheters (CVCs) requires you to take each step individually to determine if you can report a separate code or if you should include that particular service in another code.
 
First, to report the PICC line on the 4-year-old patient, use 36568 (Insertion of peripherally inserted central venous catheter [PICC], without subcutaneous port or pump; under 5 years of age). Note that this code is marked with a "conscious sedation" symbol, meaning you should not report a separate code for conscious sedation with 36568. If you use radiological imaging for the placement, report - if appropriate - one of the following add-on codes:

+75998 - Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (list separately in addition to code for primary procedure)
+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). Remember: CPT guidelines tell you that to report a CVC code, the tip must end in the subclavian, brachiocephalic or iliac veins, the superior or inferior vena cava, or the right atrium.
 
If you inject contrast into a central line to determine if it's obstructed (in other words, checking for patency), report unlisted-procedure code 36299 (Unlisted procedure, vascular injection), unless your payer tells you otherwise in writing. As with any unlisted-procedure code, send in documentation explaining the procedure, why the patient needed it, and what reimbursement you believe you deserve.
 
Good news: Chemotherapy injections are separately payable, so be sure to report these codes in addition to the CVC placement.
 
Bad news: You don't have a separate code for removal of the CVC if you only have to remove the skin sutures holding the catheter in place. Instead, you include this service in the E/M code you report for that date of service. If the catheter is "tunneled" under the skin, you do have separate procedure codes to report that device removal (36589 and 36590).