Insertion of Tunneled Catheter

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Insertion of Tunneled Catheter

• ASDIN Coding University

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Primary Secondary

• As with other procedures there are primary codes
  that are used in virtually every tunneled
  catheter placement procedure and secondary codes
  for procedures that are used only when
  exceptional events occur
• We shall consider these separately

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Primary Codes

• Used in virtually every TDC placement procedure

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Ultrasound Guidance

• The code for ultrasound guided cannulation when
  inserting a tunneled catheter is 76937
• The descriptor for this code is - ultrasound
  guidance for vascular access requiring ultrasound
  evaluation of potential access sites,
  documentation of selected vessel patency,
  concurrent realtime ultrasound visualization of
  vascular needle entry, with permanent recording
  and reporting

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Requirements for Code Usage

• As indicated in the descriptor, use of 76937
  requires that an image be recorded and made part
  of the permanent record
• As the descriptor states, this requires
  concurrent realtime ultrasound visualization of
  the vascular needle entry
• Additionally, the record should include a
  narrative documented description of the
  localization process for which the guidance was
  utilized

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Restrictions for Code Usage

• 76937 code should not be used in cases where the
  vein is only examined by ultrasound and the
  cannulation is not actually ultrasound guided
  (real-time)
• 76937 is an add-on code and requires that the
  primary procedure also be listed, in this case
  that would be 36558 for catheter insertion

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Fluoroscopic Guidance

• The code for fluoroscopic guidance used in
  connection with the placement of a central venous
  device is 77001
• The descriptor for this code is - fluoroscopic
  guidance for central venous access device
  placement, replacement (catheter only or
  complete), or removal (includes fluoroscopic
  guidance for vascular access and catheter
  manipulation, any necessary contrast injections
  through access site or catheter with related
  venography radiologic supervision and
  interpretation, and radiologic documentation of
  final catheter position)

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Code Includes Angiographic Studies

• As indicated, 77001 also includes any necessary
  contrast injections through the access site or
  catheter with related venography radiologic
  supervision and interpretation, and radiographic
  documentation of the final catheter position
• It is possible to have an angiographic study
  qualify as a separate procedure if it is done by
  selective catheterization or if it is done from a
  separate access site
• In such an instance, a 59 modifier should be
  attached to the code to indicate that it is a
  separate procedure

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Add-On Code

• The code 77001 is an add-on code and requires
  that the primary procedure also be listed, which
  would be 36558 the code for catheter insertion
• The code 77001 cannot be used with 77002 which
  is the code for using a target device for
  cannulation

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Catheter Insertion

• The code used for the actual catheter insertion
  is 36558
• The descriptor for 36558 is insertion of
  tunneled centrally inserted central venous
  catheter, without subcutaneous port or pump, over
  5 years of age
• This code is for the procedure in which a single
  tunneled catheter is inserted

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Double Catheter

• If two structurally separate catheters are
  inserted into two separate venous sites, the
  appropriate code would be 36565
• The descriptor for this code is - insertion of
  tunneled centrally inserted central venous access
  device, requiring two catheters via two separate
  venous access sites, without subcutaneous port or
  pump
• The descriptor indicates that if 36565 is to be
  used, the two catheters must be inserted via
  separate access sites
• A dual catheter inserted through a single venous
  access site would not qualify

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Secondary Codes

• Used when an unusual circumstances arises

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Fluoroscopic Guidance for Needle Placement

• In some instances the internal jugular vein
  cannot be cannulated directly and a device such
  as an angioplasty balloon or a snare might be
  inserted and used as a target for cannulation
  with fluoroscopic guidance for the cannulation
  needle placement
• The recommended code for this procedure is 77002
• The descriptor for this code is - fluoroscopic
  guidance for needle placement (e.g., biopsy,
  aspiration, injection, localization device)

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77002 Includes Angiography

• 77002 also includes any necessary contrast
  injections through the access site or catheter
  with related venography radiologic supervision
  and interpretation, and radiographic
  documentation of the final catheter position
• It is possible to have an angiographic study
  qualify as a separate procedure if it is done by
  selective catheterization or if it is done from a
  separate access site
• In such an instance, a 59 modifier should be
  attached to the code to indicate that it is a
  separate procedure

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77002 Restrictions

• The code 77002 is not an add-on code
• It is a column 2 code to 36558 (catheter
  insertion)
• It can be used with 36558 but does require a
  modifier, in the instance described here, a 59
  modifier would be appropriate
• It is a column 1 code to 77001 and the two are
  mutually exclusive (cant be used together)

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Venous Angioplasty

• If a significant stenosis is encountered when a
  tunneled catheter is being placed and is treated
  with angioplasty, then the appropriate codes for
  that procedure should be recorded
• The code for venous angioplasty is 35476, its
  descriptor is transluminal balloon angioplasty,
  venous
• Code 75978 describes the radiological supervision
  and interpretation, its descriptor is -
  transluminal balloon angioplasty, venous,
  radiological supervision and interpretation
• If a venous angioplasty is performed, then the
  use of 77001 (or 77002) will require a 59
  modifier since this would combine the use of a
  diagnostic and a therapeutic RSI code

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Aborted Cannulation Site

• If, after cannulating and examining a vein
  angiographically, it is decided to abandon that
  site and move to another, additional codes may be
  warranted to account for the work that was done
• At the aborted site this often includes
• Ultrasound guidance for cannulation
• Cannulation
• Fluoroscopy and angiography
• These procedures are coded differently since a
  catheter is not inserted at the aborted site

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Ultrasound Guidance for Cannulation

• The recommended code for ultrasound guided
  cannulation of an aborted site is 76937
• The descriptor for this code is ultrasound
  guidance for vascular access requiring ultrasound
  evaluation of potential access sites,
  documentation of selected vessel patency,
  concurrent realtime ultrasound visualization of
  vascular needle entry, with permanent recording
  and reporting
• This is an add-on code and must be used with a
  primary code, in this instance that code would be
  36410 (next slide)
• Image documentation in the medical record is
  required

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Cannulation of Aborted Site

• Unlike the usual situation, the ultrasound
  guidance code, 76937, does not include the
  cannulation
• The code 36410 is recommended for cannulation of
  an aborted site
• The descriptor for this code is - venipuncture,
  age 3 years or older, necessitating physician's
  skill (separate procedure), for diagnostic or
  therapeutic purposes (not to be used for routine
  venipuncture)

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Fluoroscopic Guidance With Aborted Site

• The use of the code 77001 can be used only for
  the site that is actually used to insert the
  catheter
• With an aborted site, the coding of the
  fluoroscopy and angiography is dependent upon the
  specific vessel involved

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Angiogram of Aborted Site

• The internal jugular vein is often involved with
  an aborted site
• If this is the case and an angiogram of that vein
  was performed, then the code 75860 would be
  warranted
• The descriptor for 75860 is - venography, venous
  sinus (e.g., petrosal and inferior sagittal) or
  jugular, catheter, radiological supervision and
  interpretation
• Additional codes might be warranted if additional
  veins are involved
• When the code 75860 is used with 36410, it is a
  column 1 code and 36410 is a column 2. In this
  instance, while the two can be used together, the
  column 2 code, 36410, would require a 59 modifier
• The medical necessity for these procedures should
  be clearly documented in the patient record and
  in the recorded images

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Important Note

• This document is for informational purposes only
  and should serve as a guideline for appropriate
  coding.
• The ultimate responsibility for correct coding
  /documentation remains with the provider of
  service. 
• ASDIN makes no representation, warranty, or
  guarantee that this compilation of information is
  error-free, nor that the use of this guide will
  prevent differences of opinion or disputes with
  CMS or any other carrier.
• ASDIN will bear no responsibility or liability
  for the results or consequences that may grow out
  of the use of this guidance.