Wiki Insertion of CVC Using Seldinger Technique

[elizabeth24]

ER physician performed a central line placement in right femoral vein with ultrasound guidance using seldinger technique. I am not sure how to choose the appropriate CPT code... I am not very familiar with central line placement and how to determine if they are tunneled or non tunneled catheters. Can anyone help? Thanks

 

[cgaston]

When I am in doubt, I will google the name of the catheter they note in the report and it will usually tell you whether or not it is a tunneled or non-tunneled catheter.

As for the Seldinger technique, there is no separate code for that, so some things to look for when selecting these codes are the age of the pateint, whether it is tunnelled or not, and whether they use image guidance or note (some codes include it and some don't).

 

[JamieAnderson]

Hi Elizabeth. Like Carol said you will need to search the report for some additional information to choose the correct CPT code. 36555- 36566 are the central line placement codes. You'll need to know the access point (which you said was right femoral vein), catheter tip end point, is it tunneled (under the skin) or non-tunneled, is there a port or a pump and patient's age (>5 or <5). 36556 is the basic central line placement for patient's over 5. If ultrasound guidance is used check out CPT 76937 (make sure documentation requirements are met). If fluoroscopic guidance is used check out CPT 77001.

 

[elizabeth24]

When I am in doubt, I will google the name of the catheter they note in the report and it will usually tell you whether or not it is a tunneled or non-tunneled catheter.

As for the Seldinger technique, there is no separate code for that, so some things to look for when selecting these codes are the age of the pateint, whether it is tunnelled or not, and whether they use image guidance or note (some codes include it and some don't).

Thank you, I am not sure they give the name of the catheter, and I am not familiar with what tunneled vs non-tunneled is. This is all new for me. Thanks for your help

 

[elizabeth24]

Hi Elizabeth. Like Carol said you will need to search the report for some additional information to choose the correct CPT code. 36555- 36566 are the central line placement codes. You'll need to know the access point (which you said was right femoral vein), catheter tip end point, is it tunneled (under the skin) or non-tunneled, is there a port or a pump and patient's age (>5 or <5). 36556 is the basic central line placement for patient's over 5. If ultrasound guidance is used check out CPT 76937 (make sure documentation requirements are met). If fluoroscopic guidance is used check out CPT 77001.

Thanks. How do you know if it is under the skin or not? This just says sutured in place. These procedure notes are short and sweet, LOL. Physician says he used ultrasound guidance.

 

[JamieAnderson]

Thanks. How do you know if it is under the skin or not? This just says sutured in place. These procedure notes are short and sweet, LOL. Physician says he used ultrasound guidance.

Hi Elizabeth,
I found a few report examples on line and the underlined text is documentation of the tunnel (under the skin) creation. If you google tunneled line catheter you can see some great pictures - I'm a visual learner so these help me understand what the report was talking about!

DESCRIPTION OF PROCEDURE: The neck was prepared in the usual manner. The skin was infiltrated with Carbocaine 0.25%. The right internal jugular vein was accessed after finding it with ultrasound. A percutaneous stick was placed. A guidewire was introduced. Through this, a sheath and dilator were introduced. Again, due to the rigidity of the neck, the patient had to be manipulated due to the 90 degree bend at the level of the cervicothoracic junction. The introducer was placed. The catheter with a wire was introduced into the superior vena cava. The catheter was then tunneled in the anterior chest wall. This was a 27 Arrow Cannon. The tubing was placed and the catheter flushed for inflow and outflow and performed well. The catheter was fastened to the skin with 3-0 Prolene. The incision was closed, subcuticular with 4-0 Monocryl, and Steri-Strips were applied. The patient left the OR in stable condition.

OPERATION IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and anesthesia was administered. Next, a #18-gauge needle was used to locate the subclavian vein. After aspiration of venous blood, a J wire was inserted through the needle using Seldinger technique. The needle was withdrawn. The distal tip location of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next, a separate stab incision was made approximately 3 fingerbreadths below the wire exit site. A subcutaneous tunnel was created, and the distal tip of the Hickman catheter was pulled through the tunnel to the level of the cuff. The catheter was cut to the appropriate length. A dilator and sheath were passed over the J wire. The dilator and J wire were removed, and the distal tip of the Hickman catheter was threaded through the sheath, which was simultaneously withdrawn. The catheter was flushed and aspirated without difficulty. The distal tip was confirmed to be in good location with surgeon-interpreted fluoroscopy. A 2-0 nylon was used to secure the cuff down to the catheter at the skin level. The skin stab site was closed with a 4-0 Monocryl. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the postanesthesia recovery area in good condition.

Thanks,
Jamie

 

[elizabeth24]

Hi Elizabeth,
I found a few report examples on line and the underlined text is documentation of the tunnel (under the skin) creation. If you google tunneled line catheter you can see some great pictures - I'm a visual learner so these help me understand what the report was talking about!

DESCRIPTION OF PROCEDURE: The neck was prepared in the usual manner. The skin was infiltrated with Carbocaine 0.25%. The right internal jugular vein was accessed after finding it with ultrasound. A percutaneous stick was placed. A guidewire was introduced. Through this, a sheath and dilator were introduced. Again, due to the rigidity of the neck, the patient had to be manipulated due to the 90 degree bend at the level of the cervicothoracic junction. The introducer was placed. The catheter with a wire was introduced into the superior vena cava. The catheter was then tunneled in the anterior chest wall. This was a 27 Arrow Cannon. The tubing was placed and the catheter flushed for inflow and outflow and performed well. The catheter was fastened to the skin with 3-0 Prolene. The incision was closed, subcuticular with 4-0 Monocryl, and Steri-Strips were applied. The patient left the OR in stable condition.

OPERATION IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and anesthesia was administered. Next, a #18-gauge needle was used to locate the subclavian vein. After aspiration of venous blood, a J wire was inserted through the needle using Seldinger technique. The needle was withdrawn. The distal tip location of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next, a separate stab incision was made approximately 3 fingerbreadths below the wire exit site. A subcutaneous tunnel was created, and the distal tip of the Hickman catheter was pulled through the tunnel to the level of the cuff. The catheter was cut to the appropriate length. A dilator and sheath were passed over the J wire. The dilator and J wire were removed, and the distal tip of the Hickman catheter was threaded through the sheath, which was simultaneously withdrawn. The catheter was flushed and aspirated without difficulty. The distal tip was confirmed to be in good location with surgeon-interpreted fluoroscopy. A 2-0 nylon was used to secure the cuff down to the catheter at the skin level. The skin stab site was closed with a 4-0 Monocryl. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the postanesthesia recovery area in good condition.

Thanks,
Jamie

Thank you so much for your help! These are done in the ER by the ER physician, so I am guessing they are not as invasive as ones performed in the operating room