Wiki Central Venous Catheter

[kdew]

I was wanting to get other professional coders opinion on what is needed in the documentation in order to bill for a central Venous Catheter. In the cpt book under the Central Venous Acess Procedure it is stated that "to qualify as a central venous catheter or device, the tip of the catheter/device must terminate in the subclavian,brachiocephalic (innominate) or iliac veins, the superior or inferior vena cava or right atrium." When the provider is documenting this procedure does it need to be stated where the tip terminates in order to bill for a central venous access catheter/device?

Thank you for you help!

 

[Om]

Yes. Golden rule of coding is "If it is documented it is done, if not documented it is not done".

 

[aswaffer]

The final placement of the catheter tip has to be documented to bill the procedure. If the final tip placement is not documented I would think you could not bill the procedure per CPT guidelines. If the catheter tip does not terminate in a required area then a modifier 52 would need to be applied. I would send this back to the physician for an addendum documenting the final catheter tip placement.