Pediatric Coding Alert

Question: What is the difference between the pediatric venipuncture CPT 36420 -36425 and 36490-36491? Are 36420-36425 for peripheral veins and 36490-36491 for a central vein?

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Answer: The code sets describe different procedures. Only 36420 (Venipuncture, cutdown; under age 1 year) and 36425 ( age 1 or over) are for venipuncture (puncture of the vein). Codes 36490* (Placement of central venous catheter [subclavian, jugular, or other vein] [e.g., for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy]; cutdown, age 2 years or under) and 36491* ( cutdown, over age 2) describe central venous catheter (CVC) placement.

The codes vary based on purpose, complexity and longevity. For instance, 36420-36425 describe an open incision to obtain access to a vein and are usually performed because the physician could not obtain intravenous access with a percutaneous stick into the peripheral vein. The doctor makes an incision into the brachial vein in younger children and possibly in the radial vein in an older child for the placement of a veni-catheter. The physician may leave the line in place for infusion.After removing the line, the doctor usually closes the incision with a layered closure.

On the other hand, 36490-36491 reflect a more complicated process with higher risk to the patient. The procedures involve inserting a line into a central and larger vein, such as the subclavian vein in the clavicle region or the jugular vein in the neck. In these situations, the physician leaves the line in place. Infusions are directly into the central venous system into the superior vena cava. These lines allow for determining the pressure in the right atrium, which reflects cardiac function, and are usually left in place for an extended time.

Both line types follow age-specific criteria, which reflect the greater level of work involved in performing the procedures on small children. For instance, because 36420 describes venipuncture for a child under age 1, 36420 carries 1.41 relative value units (RVUs) whereas 36425 has 1.03 RVUs. Similarly, the RVUs for 36490-36491 represent the work involved in performing CVC placement for different age children. Because 36490 requires performing the procedure on children age 2 years or younger, the code contains 2.67 RVUs compared to 36491, which has 2.32 RVUs. Select the code based on the child's age on the date of service, not the date of submission to the payer.

Answers to You Be the Coder and Reader Questions provided by Michael A. Ferragamo Jr., MD, FACS, clinical assistant professor of urology for the Health Science Center at the State University of New York in Garden City; Dalrona Harrison, RN, BS, CCS-P, CPC, approved American Academy of Professional Coders Professional Medical Coding Curriculum instructor and coding manager for Via Christi Medical Management in Wichita, Kan.; and Sherry Wilkerson (Straub), RHIT, CCS, CCS-P, coding and compliance manager for Esse Health in St. Louis.