Radiology Coding Alert

Central, tunneled, and other key terms narrow the list of coding options.

You've got a baker's dozen of central venous catheter insertion codes to choose from: 36555-36571. Simplify sorting through these 13 codes by answering five essential questions.

1. Do 36565 and 36566 Apply?

In the (relatively uncommon) case when the physician inserts a tunneled central venous access (CVA) device requiring two catheters with two different access sites (also known as a Tesio catheter or double catheter access device), 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 (e.g., 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, with Albany Medical Center in Albany, N.Y.

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.

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 physician 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. In contrast, a peripherally inserted device (often identified as a PICC line in documentation) 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 physician 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.

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).

In your final coding, don't forget to report the imaging used, such as +76937 (Ultrasound guidance for vascular access ...) or +77001 (Fluoroscopic guidance for central venous access device ...).