Radiology Coding Alert

Think age doesn't matter? New CV access codes say otherwise

CPT Codes 2004 includes over 20 new central venous (CV) access codes, but you can seamlessly replace the old codes with the new - as long as you know the type of access device that the radiologist inserted, the patient's age, and whether the physician used ultrasound or fluoroscopic guidance during the insertion.

The AMA revised the CV access codes for several reasons, including evolving technology with new catheter types and the need for appropriately valued guidance codes, says William T. Thorwarth Jr., MD, CPT editorial panel member, who spoke about the new CV access codes at the AMA's CPT Symposium in November 2003.

The following three tips will help you select the appropriate CV access code every time.

1. Determine What Type of Catheter the Physician

Inserted. A quick perusal of CPT 2004 offers two full pages of CV access insertion codes. To narrow down your code choice, determine whether the physician inserted a tunneled catheter, a nontunneled device or a peripherally inserted central venous catheter (PICC), and whether he used a subcutaneous port or pump during the procedure.

When the radiologist places the line percutaneously for short-term use, he probably uses a nontunneled catheter (36555-36556). If, however, the physician intends to use the line for prolonged periods, tunneling the catheter under the skin adds a bit of work to the procedure but also makes it more difficult for bacteria to migrate along the catheter into the blood stream. The term "subcutaneous port" means that the whole catheter, including the point of access, is under the skin and is less likely to get contaminated. The tunneled catheter insertion codes are 36557-36566. You should never assume that the inserted device is tunneled or nontunneled, and with or without a subcutaneous port or pump. The procedural report should explicitly state what the physician inserted.

Physicians normally insert PICC lines through a peripheral vein and then negotiate them into the central venous circulation rather than inserting them directly into a central vein. You should report 36568-36569 for externally accessible PICC line insertion, and 36570-36571 for peripherally inserted central venous access devices with subcutaneous ports.

"In the past," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, HIM program coordinator at Clarkson College in Omaha, Neb., "there was only really one choice of codes for placement of either centrally inserted or peripherally inserted lines. The emphasis on outpatient care has led to more and more use of PICC lines, and having codes to describe this work will be very valuable."

And don't bother looking for a PICC line removal code when the patient no longer needs that temporary access line. "There's no removal code for the nontunneled (PICC) line, and there never was one in the past," says Carrie Caldewey, RCC, CPC, coding specialist at Redwood Regional Medical Group in Santa Rosa, Calif. "My guess would be that the work of removal was  considered when assigning the relative value units for the placement code." In rare complicated catheter removal cases requiring imaging, you can report the imaging code.

2. Confirm the Patient's Age. CPT breaks down the new central venous access insertion codes based on the patient's age, as follows:

Under 5 years of age: 36555, 36557, 36560, 36568, 36570.

Ages 5 years or older: 36556, 36558, 36561, 36569, 36571.

Suppose a 4-year-old patient with a ventriculoperitoneal shunt for hydrocephalus develops a severe infection of the ventricular end of the shunt. He is hospitalized and receives antibiotics for seven days through a PICC line. Prior to CPT 2004, you would have reported 36489 (... percutaneous, over age 2) for this patient with no distinction for his age. Now, you should report 36568 (Insertion of peripherally inserted central venous catheter [PICC], without subcutaneous port or pump; under 5 years of age) for the PICC insertion, along with the appropriate guidance code, if applicable (see tip #3 below for more information on guidance).

3. Determine Whether the Radiologist Used Fluoroscopic or Ultrasonic Guidance to Place the Line. The radiologist often uses fluoroscopic or ultrasonic guidance when inserting a CV access device. You should report these imaging services separately, as long as your documentation meets the CPT criteria.

If the physician uses ultrasound guidance, you should report the add-on code +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]) along with your insertion code. At the CPT Symposium, Thorwarth said that you can only report this code once per session, even if you examine multiple sites to select the best one for access.

And, you should report 76937 only if the same physician reports both the vascular access procedure and the ultrasound, according to the AMA's CPT Changes 2004 - An Insider's View. You should report this code only if you include documentation in the form of an image of the vascular access site in the patient's record, along with a documented description of the placement procedure. "Therefore," CPT Changes 2004 states, "for those instances when ultrasound is used only to identify a vein, mark a skin entry point and proceed with nonguided puncture, it would not be appropriate to report 76937."

If the radiologist uses fluoroscopic guidance, you should report +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]).

You should report 75998 as an add-on to codes 36555- 36585 when the physician uses fluoroscopic imaging to guide the guidewire and the catheter into the central venous position, according to CPT Changes 2004 - An Insider's View. It also indicates that you should report 75998 only if the same physician performs both the insertion procedure and the guidance, and states, "Any contrast injection through the access site (via needle, catheter or sheath) for venographic evaluation and mapping of appropriate path is included," so you should not separately report the contrast injection or a diagnostic imaging study.