Radiology Coding Alert

CPT may have 13 central venous access (CVA) device and catheter insertion codes, but you don't have to feel unlucky when you have to choose among them for your interventional radiologist's claim. If you follow the four steps below, you can feel confident you've found the best option for your case.

The first thing you need to do when choosing a CVA code is look at the type of catheter your physician used: a tunneled catheter, a non-tunneled device, or a peripherally inserted central venous catheter (PICC), says Sundae Yomes, CPC, coder at HCA Physician Services in Las Vegas.

Caution: You should never assume " your radiologist's report should state explicitly what he inserted.

Non-tunneled: If your radiologist places the line percutaneously for short-term use, he probably uses a non-tunneled catheter:

• 36555 -- Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age

• 36556 -- ... age 5 years or older.

Tunneled: If the physician instead 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 tunneled catheter/device insertion codes are as follows:

• 36557 -- Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; younger than 5 years of age

• 36558 -- ... age 5 years or older.

• 36560 -- Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; younger than 5 years of age

• 36561 -- ... age 5 years or older.

• 36563 -- Insertion of tunneled centrally inserted central venous access device with subcutaneous pump.

• 36565 -- Insertion of tunneled centrally inserted central venous access device, requiring two catheters via two separate venous access sites; without subcutaneous port or pump (e.g., Tesio type catheter)

• 36566 -- ... with subcutaneous port(s).

One access point or two? In the relatively uncommon case when the radiologist inserts a tunneled CVA 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 and 36566.

PICC: 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. For PICC line insertions, you'll use a code from the 36568-36571 range:

• 36568 -- Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; younger than 5 years of age

• 36569 -- ... age 5 years or older.

• 36570 -- Insertion of peripherally inserted central venous access device, with subcutaneous port; younger than 5 years of age

• 36571 -- ... age 5 years or older.

Next, determine whether the physician used a subcutaneous port or pump during the procedure, says John F. Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop and Associates. The access device may include a subcutaneous port, pump, or both, to administer medication directly into the vein.

Without pump or port: Codes describing procedures without a pump or port include 36555-36558, 36565, 36568, and 36569.

Port: Codes 36560, 36561, 36566, 36570, and 36571 describe procedures with a port.

Pump: Code 36563, on the other hand, describes a procedure with a pump.

Your next step will be to read through the physician's documentation to find out if she centrally inserted or peripherally inserted the catheter. To determine this, you must know exactly which vessel the venous access device accesses. "Coders really need to know their anatomy," Bishop says.

Rule: CPT establishes that central venous access catheters or devices must terminate in the subclavian, brachiocephalic (innominate), or iliac veins, the superior or inferior vena cava, or the right atrium.

Central: To be a central insertion, the access site (where the catheter enters the vascular system) must be in an artery close to the central circulatory system, usually the jugular, subclavian, or femoral vein -- or sometimes the inferior vena cava. For a centrally inserted access device, you must choose from 36555-36566.

PICC: A peripherally inserted device (or PICC line), in contrast, accesses the central venous system via the basilic or cephalic vein. For a peripherally inserted device, look to 36568-36571.

Ask for clarification: If you cannot find the information you need to determine the insertion type, go back to your physician for clarification, Yomes says. "When in doubt, ask for help," she adds.

Your final step in choosing the proper CVA insertion code is determining the patient's age. Because CPT divides most of the CVA codes into "younger than 5" and "age 5 years or older" categories, you can automatically eliminate almost half your code choices simply by knowing the patient's age.

For patients under age 5, check out 36555, 36557, 36560, 36568, and 36570. For patients 5 years old or older, you can concentrate on 36556, 36558, 36561, 36569, and 36571.

Exception: Code 36563 does not specify "younger than 5 years of age" or "age 5 years or older," so you should not rule out this code based on the patient's age.

Bonus step: Be sure you capture radiologic guidance for CVA, as well, following the tips in "Seize Rightful CV Access Guidance Pay With 2 Options" on page 83.