Central Venous Access Procedures

Deborah Grider, CPC, CPC-P, CPC-I, COC, CPMA, CEMC, CCS-P, CDIP

Central venous access procedures are commonly performed in critical care. Some vascular access codes are included in critical care and not billed separately, such as:

• 36600: Arterial puncture, withdrawal of blood for diagnosis
• 36410: Venipuncture, patient’s age 3 years or older, necessitating the skill of a physician or other qualified healthcare professional (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture)
• 36415: Collection of venous blood by venipuncture
• 36591: Collection of blood specimen from a completely implantable venous access device
• 36600: Arterial puncture, withdrawal of blood for diagnosis

Other venous access procedures not included in critical care may be reported in addition to critical care coding. According to the CPT Assistant, “to qualify as a central venous access 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 the right atrium”.¹

The venous access device may be inserted centrally—into the jugular, subclavian, femoral vein, or inferior vena cava catheter entry site, or inserted peripherally—for example, through the basilic or cephalic vein. The two most commonly used sites are the jugular and subclavian veins. The device may be accessed through an exposed catheter (one that is external to the skin), a subcutaneous port, or a subcutaneous pump.

Five Categories Define Central Venous Access Procedures
There is no coding distinction between venous access achieved percutaneously by cut-down or by catheter size. Understanding which codes to use is critical to making certain you are reporting the procedures accurately. The five categories of central venous access procedures are:

1. Catheter insertion through a newly established venous access site
2. Repair of a device without replacement of either the catheter or port/pump, other than for pharmacologic or mechanical correction of intracatheter or pericatheter occlusion
3. Partial replacement of only the catheter component associated with a port/pump device, but not the entire device
4. Complete replacement of entire device via the same venous access site (complete exchange)
5. Removal of entire device

For the repair, partial (catheter only) replacement, complete replacement, or removal of both catheters (placed from separate venous access sites) of a multicatheter device, with or without subcutaneous ports or pumps, report the appropriate Current Procedural Terminology (CPT) code describing the service with a frequency of 2. If the physician removes an existing central venous device (report removal if code exists) and replaces the device through a separate venous access site, both removal and the new device may be reported. Report CPT codes 76937 (ultrasound) or 77001(fluoroscopy) when using imaging to either gain access to the venous site or manipulate the catheter into final position.

CPT codes for Insertion of a centrally inserted venous catheter without a pump are selected based on the patient’s age and whether the catheter is tunneled or non-tunneled. Keep in mind that CPT code 36555 is included in the pediatric critical care codes and cannot be reported separately, but it can be reported for adult critical care.²

Device Insertion Codes​

Coding Tip: Moderate conscious sedation can be reported separately if performed for a tunneled catheter insertion.

The following CPT codes are reported for the insertion of a tunneled centrally inserted venous catheter with or without port or pump. The codes are selected based on the patient’s age and whether a subcutaneous port or pump is used. In addition, these procedures have a 10-day global period. Moderate conscious sedation and ultrasonic guidance or fluoroscopy can be reported in addition to the procedure. CPT codes 36565 and 36566 require 2 catheters with 2 separate access sites.



CPT codes for the insertion of a peripherally inserted venous catheter with or without a port or pump are selected based on the patient’s age and whether a subcutaneous port or pump is used. Moderate conscious sedation and ultrasonic guidance or fluoroscopy can be reported in addition to the procedure.



CPT codes for the repair of a central or peripheral central venous access device are dependent on whether it is without a subcutaneous port or pump. Imaging guidance, including ultrasound or fluoroscopy, can be reported in addition to the repair.



Device Replacement Codes
Device replacement with moderate conscious sedation can be reported with CPT codes 99151-99153 when performed by the primary physician and 99155-99157 when performed by another physician. In addition, 76937 (ultrasound guidance) or 77001 (fluoroscopic guidance) can be reported for either obtaining access to the venous access site or for manipulation of the catheter to its end position. The global period is 0-10 days depending on the procedure performed.



Documentation
Many commercial carriers and Medicare contractors have local carrier determinations3 for reporting vascular access procedures. It is important to reference these policies to understand payer requirements. Documentation is key in reporting these procedures. Documentation should include:

• Guidance used (fluoroscopy or ultrasound)
• Vein entry site
• Tunneled versus non-tunneled
• Subcutaneous pump (if in place)
• Final catheter tip position
• Patient’s age

Device Removal Codes
CPT codes 36589 and 36590 (central venous access device) are reported for the removal of a tunneled central venous catheter. Imaging guidance, including ultrasound or fluoroscopy, can be reported in addition to the procedure.



Mechanical Removal Codes
CPT codes 36595 and 36596 are reported for the removal of obstructed material. Code 36596 cannot be used with code 36593 (declotting by thrombolytic agent of implanted vascular access device or catheter) because 36593 is included in 36596. CPT code 75901 (mechanical removal of pericatheter obstructive material [e.g., fibrin sheath] from central venous device via separate venous access, radiologic supervision, and interpretation) can be reported with 36595 and CPT code 75902 (mechanical removal of intraluminal [intracatheter] obstructive material from central venous device through device lumen, radiologic supervision, and interpretation) in addition to CPT 36596.



When a previously placed central venous catheter needs to be repositioned, report CPT code 36597 (repositioning previously placed central venous catheter under fluoroscopic guidance). You can also report CPT code 76000 for the fluoroscopic guidance.

When evaluating an existing central venous device, report CPT code 36598. This code is reported for complications that might be interfering with proper function or the ability to draw blood from the catheter. Complications include the presence of a fibrin sheath around the end of the catheter, migration of the catheter tip, patency of the tubing, kinking, fracture, or leaks. Fluoroscopic guidance is included in CPT code 36598 and should not be reported separately.

Imaging Guidance
For many of the vascular access procedures, imaging guidance, including ultrasound and fluoroscopy, can be reported in addition to the vascular access procedure. For example, when reporting ultrasound guidance using CPT code 76937, documentation should include the access site; vessel patency; concurrent real-time ultrasound needle entry, including the pre-access assessment of venous patency; and real-time visualization of needle passage to the venous lumen. There must be a permanent recording when reporting ultrasound.³

For fluoroscopy, a simple statement in the procedure note stating that fluoroscopic guidance was used to gain access and check placement is sufficient. Remember to append modifier 26 to the fluoroscopy code when fluoroscopy was performed in the hospital to indicate that the clinician provided only the professional component.

Remember that, if you are providing critical care services on the same date as that of any vascular access procedures, append modifier 25 to the critical care service to indicate that the evaluation and management service is significant and separately identifiable.

Sources:

• CPT Assistant. Chicago, IL: American Medical Association.
• Centers for Medicare and Medicaid Services. Physician Fee Schedule. Washington, DC: Centers for Medicare and Medicaid Services.

References

1. American Medical Association. Coding Communication: Update to Central Venous Access Codes. CPT Assistant. Chicago, IL: American Medical Association; 2004:6.
2. American Medical Association. CPT 2018 Professional. Chicago, IL: American Medical Association; 2017;44.
3. CGS Administrators. Reporting Ultrasound Guidance for Vascular Access (CPT code 76937). Nashville, TN: CGS Administrators; 2012. https://www.cgsmedicare.com/partb/pubs/news/2012/1012/cope20331.html. Accessed July 24, 2018.