Part B Insider (Multispecialty) Coding Alert

Hint: Know how many access points the physician addressed before selecting a code.

CPT® includes 13 codes for central venous catheter insertion (36555-36571), which gives you a wealth of choices to weed through. The next time your anesthesiologist inserts one of these lines during surgery, ask yourself five questions to narrow your options to the correct code.

1. How Many Access Points?

In the (relatively uncommon) case when the physician inserts a tunneled CVA (central venous access) device requiring two catheters with two different access sites (also known as a Tesio catheter), you can narrow your code selection to just two codes:

• 36565 -- Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters via 2 separate venous access sites; without subcutaneous port or pump (eg, Tesio type catheter)
• 36566 -- Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters via 2 separate venous access sites; with subcutaneous port(s).

"Using two catheters is more common for dialysis," says Scott Groudine, MD, an anesthesiologist with Albany Medical Center in Albany, N.Y. "Anesthesiologists might sometimes place two lines, but the second line isn't 'required' as part of the placement" we just want lots of access."

Result: If your anesthesiologist documents two lines, verify whether he inserted them to have better access during the procedure, or whether the two lines were required. Your better coding option might be to report the lines as separate and distinct.

2. How Old Is the Patient?

CPT® divides most of the CVA codes into "under 5" and "age 5 years or older" categories. Because of this, you can automatically eliminate almost half your code choices simply by knowing the patient's age.

• For patients under age 5, your immediate code choices are 36555, 36557, 36560, 36568 and 36570.
• For patients 5 years old or older, you can concentrate on codes 36556, 36558, 36561, 36569 and 36571.

One exception: One venous access code, 36563 (Insertion of tunneled centrally inserted central venous access device with subcutaneous pump) does not designate the patient's age. That means you should not rule out reporting 36563 based on the patient's age.

3. Is It a Central or Peripheral Insertion?

Now, check your documentation to see if the surgeon inserted the access device centrally or peripherally. To determine this, you must know exactly which vessel the venous access device accesses.

A centrally inserted device usually enters the jugular, subclavian or femoral vein. A peripherally inserted device (often identified as a PICC line in surgeon documentation), in contrast, accesses the central venous system via a peripheral vein, says Gary W. Barone, MD, associate professor of surgery at the University of Arkansas for Medical Sciences in Little Rock.

Central choices: Again, the process of elimination allows you to narrow your code selection. For a centrally inserted access device, choose among 36555, 36556, 36557, 36558, 36560, 36561, 36563, 36565, and 36566. Once you factor in the patient's age, the list narrows even further.

Peripheral choices: For a peripherally inserted device, your options are 36568, 36569, 36570, and 36571.

4. Is the Catheter Tunneled?

Next, determine whether the anesthesiologist tunneled the catheter under the skin or left it exposed. Tunneling describes a technique in which the physician places a long catheter under the skin between the vein entry and external access sites.

"In other words," Groudine says, "the external site where the catheter leaves the patient is several centimeters away from where the catheter enters the vein." Tunneling makes it more difficult for bacteria migrating along the catheter from the skin to reach the blood stream.

Codes for tunneled catheters include 36557, 36558, 36560, 36561, 36563, 36565 and 36566.

For non-tunneled catheters, your choices include 36555, 36556, 36568, 36569, 36570 and 36571.

Example: The physician inserts a tunneled CVA device with a single access site into the jugular vein of a 4-year-old patient. Because the device has one access point, you can rule out a Tesio-type catheter (36565, 36566). You'll eliminate other possibilities because the patient is under age 5 and because you're reporting a centrally inserted device. This leaves you to select from codes 36555, 36557, 36560 and 36563. The tunneled catheter further narrows your code choices to 36557 and 36563.

Also note: "The surgeon often tunnels the catheter and we provide anesthesia when necessary," points out Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. "In that case, the anesthesia crosswalk code will depend on whether the surgeon completed a placement or repair." For catheter placement, report anesthesia code 00532 (Anesthesia for access to central venous circulation). For repair, select 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified).

5. Is There a Pump and/or Port?

The final step in deciding the correct CVA code is verifying whether the access device includes a subcutaneous port and/or pump for injecting and/or administering medication directly into the vein.

Codes describing venous access devices without a pump or port include 36555, 36556, 36557, 36558, 36565 and 36568. For a venous access device with either a pump or port, your choices are 36570 and 36571. Codes 36560, 36561 and 36566 describe procedures with a port only, while 36563 describes a procedure with a pump only.

Example: Returning to our example, a review of the documentation shows that the access device does not include a subcutaneous port or pump. Therefore, the appropriate code in this case is 36557 (Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; younger than 5 years of age).

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