CCS Prep

Procedural Coding of the Insertion of Central Venous Access Procedures: CPT vs. ICD-9-CM

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Simply put, venous catheterization is a way to access veins. A central venous access catheter or device is used to deliver medications, intravenous fluids or obtain blood samples. Central venous access catheters and central venous access devices (VADs) are two different methods of venous catheterization. The appropriate procedural coding of central venous catheters and central venous devices (CVD) is somewhat problematic for many coders. This is in part due to the terminology used by physicians when describing the catheters and devices inserted. Some physicians use the term "vascular access device" to mean any type of central venous catheterization without providing adequate information as to the precise type inserted, whether it is a non-tunneled or tunneled central venous catheter or the insertion of a tunneled, implantable, either partially or totally, central VAD as defined in Coding Clinic and CPT Assistant. Also, the physician may not always document if the insertion site is central or peripheral. This lack of precise documentation for the procedures causes confusion and frustration on the part of the coder. This article will clarify the procedures and their associated codes for the insertion of intravenous central venous access catheters or devices, from both CPT and ICD-9-CM perspectives.

Central venous catheters or central lines, as they are also known, are placed in large veins, such as the subclavian or jugular veins. These veins are located in the neck or chest. There is another type of central venous catheter that is peripherally inserted in the arm or upper leg. It is called the peripherally inserted central catheter, or PICC. Peripheral venous catheters are inserted into superficial veins, generally in the arms, legs, feet or head. A nurse at bedside usually performs peripheral venous catheter insertion. For a catheter to be considered a central line, the catheter must terminate in either the subclavian, brachiocephalic, innominate or iliac veins, or at the junction of one of these veins with the superior or inferior vena cava.

CVDs are also known as implantable CVDs, as implantable vascular or VADs, as implantable venous access ports and as totally implantable vascular access device (TIVAD). The vascular access device is implanted in the body to provide easy access to the vascular system. VADs are designed to provide long-term, repeated access to the vascular system without the trauma of repeated needle sticks. Patients requiring total parenteral nutrition (TPN), chemotherapy, dialysis, etc. are good candidates for these devices.

A completely implanted VAD, also known as a port, consists of two parts, an injection port that looks like a small hat and a sterile catheter system. The insertion of this port is an operative procedure. This is another clue for the coder to look for in the coding of an implantable CVD, an operative report. The catheter itself is placed in central, large, deep veins, such as the subclavian and jugular rather than peripheral veins and then tunneled through the subcutaneous tissue. This tunneling technique is another very important clue for the coder to look for when determining the correct code to assign. The catheter is then anchored at or below the subcutaneous tissue. Thus, the catheter is totally embedded. After the insertion of the catheter, the surgeon will make a small space called a "pocket" under the skin to hold the port. This is generally in the chest region but can be on the arm. The catheter is then connected to the port, and the port is stitched into place. The pocket is then closed. The port can then be accessed as needed, percutaneously by a noncoring needle, such as a Huber or Angiocath. Some examples of implantable venous access ports are Medi-port, Port-a-cath, Infus-a-port, P.A.S. Port, and Groshong port.

Another type of VAD is a partially implanted VAD, which consists of a tunneled catheter, one that is longer than a simple venous catheter because it must reach from below the nipple level to the subclavicular area. Its placement is also an operative procedure, just as is the totally implantable port. The catheter is typically inserted in the subclavian vein just below the collarbone or into the internal jugular vein in the neck. It is then tunneled through the subcutaneous tissue and brought out and generally sutured to the skin. Access to the vein is through the end of the catheter itself. The creation of this tunnel is a specific and separate surgical step, and not a simple skin incision with a dilation of a tract. This tunneling step is very important clue for the coder to look for when determining the correct code to use. Examples of partially implanted VADs, tunneled catheters, are Hickman, Broviac, Leonard and Ventra.

To summarize, there are two types of VADs: one completely implanted and the other partially implanted. Both types of VADs are designed to provide repeated access to the vascular system without the trauma or complications of multiple veni-punctures. Like simple venous catheters, when not in use, VADs are flushed with a saline or heparinized solution to maintain patency. However, unlike simple catheters, VADs can be left in place for weeks or months as opposed to days. VADs are generally placed in patients who require long-term access for chemotherapy, total parenteral nutrition (TPN) or blood withdrawal. These patients will usually have compromised immune systems, which predispose them to increased incidence of infection. VADs provide necessary vascular access with minimal manipulation and reinsertion, thereby reducing the risk of infection. The completely implanted device is usually called a port, while the partially implanted device refers to a tunneled catheter. Both procedures are operative procedures and are carried out in the operating room, interventional radiology suite or a special procedure room.

For the year 2004, CPT has provided new, distinct codes for non-tunneled and tunneled central venous access procedures. Therefore, the initial words to focus on when coding the insertion of central venous access procedures are "non-tunneled" and "tunneled." The next key word is catheter or device. The non-tunneled central venous access catheter may be placed either centrally or peripherally, with a different set of codes assigned according to the insertion site, central or peripheral, as well as according to the age of the patient. Non-tunneled, centrally placed venous access catheters and non-tunneled peripherally inserted central venous catheters will not have a port or pump. The new codes are: 36555 (insertion of non-tunneled centrally inserted central venous catheter, under 5 years of age), and code 36556 for age 5 years or older. The insertion of a non-tunneled, peripherally inserted central venous catheter, or PICC, is also broken down by age. The new codes are 36568 (insertion of a non-tunneled peripherally inserted central venous catheter, without subcutaneous port or pump, under 5 years of age), and 36569 for age 5 years or older.

CPT also has provided new codes for the insertion of tunneled central VADs, whether they are catheters or devices, as well as for peripherally inserted central VADs. The tunneled central venous catheter codes are broken down by age. The code for the insertion of a tunneled centrally inserted central venous catheter, without a subcutaneous port or pump, under 5 years of age is 36557, and code 36558 for age 5 years or older. There are five new codes for centrally inserted central VADs, each with differing qualifications. The codes for a tunneled centrally inserted central VAD with a subcutaneous port are broken down by age. The code for the insertion of a tunneled CVD with a pump is a stand-alone code and is not broken down by age. In addition, the two new codes for the insertion of Tesio type catheters, where the tunneled centrally inserted central VAD requires two catheters via two separate venous access sites, are qualified by the use or lack thereof of a subcutaneous port or pump. They are not delineated by age. Additionally, there are two new codes for peripherally inserted central VADs, with subcutaneous ports, again broken down by the age of the patient.

Code 36560 is for the insertion of a tunneled centrally inserted central VAD with subcutaneous port, under 5 years of age, and code 36561 is for age 5 years or older. Code 36563 is for the insertion of tunneled centrally inserted central VAD with subcutaneous pump. Code 36565 is for the insertion of a tunneled centrally inserted central VAD, requiring two catheters via two separate venous access sites, without subcutaneous port or pump (e.g. Tesio type catheter), and code 36566 is for the same but with a subcutaneous port(s). The new codes for the insertion of peripherally inserted central VAD, with a subcutaneous port, under 5 years of age is 36570, and 36571, for age 5 years or older. One has to keep in mind that if the term device is used, port is inherent in that definition.

In summary, centrally inserted central venous catheters may be non-tunneled or tunneled. They may be placed in patients under 5 years of age or age 5 years and older. The centrally placed catheters, whether non-tunneled or tunneled, do not have a subcutaneous port or pump. If the centrally inserted central venous catheters are tunneled, they are also known as partially implanted vascular access devices. Central venous access devices are inserted using a tunneling technique. They are also known as VADs. The codes for the central venous access device with a subcutaneous port are differentiated by the patient's age. The code for the central VAD with a subcutaneous pump is not, there being only one code for this procedure. The codes for the insertion of the CVD requiring two catheters via two separate venous access sites (e.g., Tesio type catheters) are differentiated based on the absence or presence of the subcutaneous port or pump, with no age qualification. Peripherally inserted central venous catheters are non-tunneled, do not have a port or pump, and are placed in patients under 5 years of age or age 5 years and older. Peripherally inserted CVDs may have a port, and are placed in patients under 5 years of age or age 5 years and older.

ICD-9-CM provides a simpler approach to the coding of the insertion of central venous catheters and VADs. For the insertion of a totally or partially implantable VAD, it provides one code, 86.07, (Insertion of totally implantable vascular access device [VAD]). It provides only two codes for the insertion of central venous catheters, code 38.93 for venous catheterization, not elsewhere classified, and code 38.95 for venous catheterization for renal dialysis. ICD-9-CM does require the addition of code 38.94, venous cutdown, should this be the approach used. As of 2004 CPT does not distinguish between venous accesses achieved percutaneously or by cutdown.

To further explain, a venous cutdown is another approach for the placement of a central venous catheter. The great saphenous vein at the ankle is the site most commonly used for the procedure. The vein is isolated and a loop thread is passed under the vein. The apex of the loop is then divided. The distal ligature is knotted and the ends of the proximal ligature are held without knotting. A needle is used to transfix the vein at the proposed site of cannulation. The circumference of the vein anterior to the needle is almost completely incised with a scalpel. The needle prevents injury to the posterior wall of the vein and also facilitates a clean-cut incision. The intravenous cannula without the inner needle is then introduced into the venotomy opening, with the needle steadying the vein. The needle is then removed, the proximal ligature tied over the cannula and the wound closed. The code 38.94 must be used in addition to ICD-9-CM code 38.93 when a central venous catheter is placed in this manner. Please refer to Coding Clinic, September-October, 1984, p. 8, for this example:

"Cutdown placement of central venous catheter for chemotherapy includes the following:

38.94, Venous cutdown

38.93, Other venous catheterization

99.25, Infusion of anticancer drug"

Another important difference in CPT and ICD-9-CM is the fact that CPT codes for central venous catherization, no matter the age and approach, include the following purposes: central venous pressure, hyperalimentation, hemodialysis and chemotherapy. In ICD-9-CM there is a separately identifiable code for central venous catheterization for renal dialysis, code 38.95. This code is to be used only for the central venous catheter for the renal dialysis. As a caution, remember that if a partially or totally implantable device is used for renal dialysis, then coded 86.07 (insertion of totally implantable vascular access device) is to be used. In addition, ICD-9-CM also includes separate codes for circulatory monitoring, codes 89.60-89.69, which are not to be used in conjunction with code 38.93. Finally, venous catheterization for cardiac catheterization in ICD-9-CM are codes 37.21-37.23 and not code 38.93.

Procedural coding of central venous access procedures depends not only on the skill and knowledge of the coder, but also the documentation provided by the physician within the medical record. The coder must carefully read the entire documentation contained within the record, including the progress notes, operative reports, radiology reports, and special procedure reports in order to correctly ascertain the device used for the patient. Should the coder be unsure of the procedure performed, the physician should be queried.

Questions

1. A new hemodialysis access system is being used to provide immediate access for end-stage renal disease patients. This system consists of two access valves and cannulas that are typically implanted below the clavicle and tunneled to the jugular vein and other central veins. The valves are designed so that a 14-gauge fistula needle may actuate an internal pinch clamp as the needle enters the valves. Once the pinch clamp is opened, blood flows. When the needle is withdrawn blood flow stops. The single lumen cannulas are attached to the valves and placed to an arterial and venous draw site. This system is ready for usage immediately after it is implanted. What ICD-9-CM procedure code is appropriate for insertion of this access system?

a. 38.93

b. 86.07

c. 38.94

d. 38.99

2. What are the correct ICD-9-CM and CPT codes for a PICC line insertion for a 62-year-old patient? The catheter is inserted via venipuncture with a guidewire introducer. The guidewire is removed and an extension set is attached to the catheter. The insertion site is then secured with steri-strips and a dressing.

a. 36568, 86.07

b. 36569, 38.91

c. 36569, 38.93

d. 36563, 38.93

3. A port was introduced through the external jugular vein into the superior vena cava and tied into place in a 73-year-old patient. It was tunneled subcutaneously into an incised area of the left anterior chest wall. The port was connected to a Port-A-Cath. The Port-A-Cath was sutured to the pectoralis. The subcutaneous tissue was sutured and the skin was closed with staples. What are the correct ICD-9-CM and CPT procedure codes?

a. 36561, 86.07

b. 36565, 38.91

c. 36563, 38.93

d. 36563, 86.07

4. If a non-tunneled method is used for the insertion of a centrally inserted central venous catheter for a 5 1/2-year-old child, which CPT code is to be used to identify the service provided?

a. 36555

b. 36556

c. 36568

d. 36571

5. A 55-year-old male needs long-term central venous access. A tunneled centrally inserted central venous dialysis catheter is placed. The appropriate CPT and ICD-9-CM procedure codes are:

a. 36558, 38.95

b. 36558, 86.07

c. 36561, 86.07

d. 36565, 38.95

This month's column has been prepared by Melinda Stegman, MBA, CCS, manager of clinical HIM services, and Beverly Finney, RHIA, senior consultant, HSS Inc. (www.hssweb.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.

Answers

1. b; Assign code 86.07 (Insertion of totally implantable vascular access device [VAD]), for the insertion of this hemodialysis access system.

2. c; There is no mention of a subcutaneous port or pump and the patient is more than 5 years of age. CPT code 36569 is most appropriate. Because the catheter is brought out through the skin, the correct code assignment is 38.93 (Puncture of vessel, venous catheterization, NEC).

3. a; Assign CPT code 36561 because a port was implanted and a tunneling technique used on a patient more than 5 years of age. Assign code 86.07 (Insertion of totally implantable vascular access device), because the catheter was sutured at or below the subcutaneous tissue (in this instance to the muscle), the catheter is totally embedded, and no portion of the catheter was brought out through the skin.

4. b; Code 36555 and code 36556 include language that references age 5 as a factor for determining use of these codes. Because the codes use age 5 as the point of reference, central line placement for anyone older than five (e.g., five years and one day or older) should be identified using the codes that reference over age 5. In a similar fashion, codes referencing age 5 years or under identify services provided for someone who is less than 5 years old (i.e., 4 years and 364 days old or younger). Therefore, in response to the specific question, if a non-tunneled method is used to place a centrally inserted central line catheter into a 5 1/2-year-old child, then code 36556 should be used to identify the specific service provided.

5. b; Because the VAD was placed via a tunneling technique without mention of a port or pump and the patient is more than 5 years of age, CPT code 36558 is most appropriate. Because a tunneling technique was used, ICD-9-CM code 86.07 must be assigned.


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