Part B Insider (Multispecialty) Coding Alert

If the surgeon bills it first, appeal with your documentation

The next time your anesthesiologist performs a central venous catheter placement (CVP), make sure his or her documentation is pristine--or the surgeon just might collect the CVP reimbursement that your practice deserves.

Scenario: Suppose the anesthesiologist performs a CVP during surgery and dictates it in his note. He later bills for the CVP (for example, 36556) and the anesthesia. His Medicare payer reimburses him for the anesthesia but not the CVP, stating that the surgeon was already reimbursed for the CVP. In these cases, the surgeon probably dictated in his note that -a central venous catheter was placed.- Because surgical notes are often written in passive voice, coders may simply assume that the surgeon placed the catheter himself, and therefore billed for it.

But your anesthesiologist's documentation specifically states, -I then inserted the central venous catheter,- so you know you have the right to collect for it.

Problem: -The problem is they are looking at paying a -duplicate- service for the same date,- says Kelly Dennis, MBA, CPC, ACS-AP, with Perfect Office Solutions in Leesburg, Fla. -What does the documentation state about who performed the service? It may boil down to having the surgeon's office return the money (if it doesn't belong to them) and then re-billing the CVP with documentation.-

Solution: -If you have documentation that the anesthesiologist placed the line, you should be able to appeal,- suggests Candy Souders, CPC, ACS-AN, lead coder at CBIZ Medical Management Professionals.

Example: -I appeal to Medicare with a copy of the ASA record showing that my doctor signed off on the placement of it,- says Kay Brown, CPC, coding specialist at Bayou Anesthesia and Pain in Spring, Texas. -I had a case that denied with reason CO-18 (duplicate). I called Medicare and was told they had already paid another doctor for it. I appealed it with a copy of the ASA record, and Medicare denied it again. I appealed it to a second level and won,- she says.

Documentation tip: To strengthen your claims and increase your chances that Medicare will rule in your favor on any appeals you might have to file, make sure the physician documents the following important line-placement details:

- Who placed the line
- What type of line was placed
- When it was placed (before or after induction, and the time associated with it)
- Where it was placed (radial or femoral for A-lines or CVPs, jugular or subclavian for PA catheters)
- The needle size
- Complications encountered (such as multiple attempts to place lines, hematomas for A-line insertions, inadequate circulation after radial artery line placement).

Consider Method for Two Catheter Insertions

Another possible impediment to collecting for CVP lines is when the anesthesiologist also inserts a Swan-Ganz catheter (93503) during the same procedure.

Solution: Coding for the CVP and Swan-Ganz placement depends partly on how your physician completed the procedure. 

Scenario 1: In some instances, the physician places a Swan-Ganz catheter through the CVP line and then threads the Swan-Ganz through the CVP for final placement. He uses the CVP placement as an intermediate step in establishing the Swan-Ganz. Therefore, you can bill for the Swan-Ganz line but not the CVP line.

Scenario 2: In other situations, the anesthesiologist might place a second CVP line for additional monitoring during the procedure. Many heart cases include two lines that the anesthesiologist inserts through separate incisions. Documenting separate incisions establishes that they are two distinct procedures, and you may bill them separately.

Terminology tip: If the physician documents placement of a pulmonary artery catheter or PA catheter, he or she actually performed a Swan-Ganz insertion. These terms all refer to the same service.