ACR Radiology Coding Source™ November-December 2003
Most significant of the CPT® code updates for 2004 are the additions, revisions, and deletions of the central venous access procedure codes. Twenty-seven new procedural codes (36555-36597) and two new add-on imaging codes (+75998, +76937) have been established, and 13 procedural codes have been deleted (36488-36491, 36493, 36530-36537) for central venous access in 2004. Because the current CPT® codes no longer represent current clinical practice or accurately describe the exchange, revision or repair of non-tunneled or tunneled catheters, the existing codes will be replaced with a more logical coding scheme—one more directly related to the work involved and more reflective of actual clinical practice.
In November 2001, the AMA CPT® Editorial Panel appointed a workgroup specifically to address the deficiencies of the central venous access procedure codes and commissioned workgroup members to create a more logical coding scheme to describe these procedures. The recommendations of this workgroup were accepted by the CPT Editorial Panel for implementation in 2004.
The workgroup developed separate categories of CVA codes because of differences in:
- type of procedure performed
- physician work
- type of device used
- insertion, i.e., central versus peripheral
- physician work for pediatric cases (ages 5 and under)
The introduction to the "Central Venous Access Procedures" section of the CPT® 2004 manual clarifies for the coder the parameters for central venous access code usage. To be considered a central venous access catheter or device the CPT® guidelines state, "... 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." Catheter/device location should be documented in the radiology report to justify use of the CVA codes.
The new structure of the CVA surgical codes is organized by: the type of procedure performed (i.e., insertion, repair, partial replacement, complete replacement or removal of a central venous device), the type of device employed in the procedure (e.g., non-tunneled central venous catheter, tunneled central venous catheter), the method of insertion [centrally inserted (jugular, subclavian, femoral vein or inferior vena cava catheter entry site) or peripherally inserted (e.g., basilic or cephalic vein)], and device access, i.e., via the use of a port or pump or via an exposed catheter. It should be noted that no distinction is made between how venous access is achieved (percutaneously or by cutdown), and no distinction is made based on catheter size.
The patient's age is used to differentiate some of the procedures, because pediatric patients less than five years old require additional work. For the more complex venous access insertion procedures in the premature infant (body weight less than 4 kg), a –63 modifier should be assigned with the appropriate CVA (30000 series) code. A –63 is not to be reported with radiology 70000 series code.
The new codes are:
Insertion
Catheter
Centrally Inserted
36555 Non-tunneled, <5 yrs
36556 Non-tunneled, >5 yrs
36557 Tunneled, without port or pump, <5 yrs
36558 Tunneled, without port or pump, >5 yrsPeripherally Inserted
36568 Non-tunneled, (PICC), without port or pump, <5 yrs
36569 Non-tunneled, (PICC), without port or pump, >5 yrs
Device
Centrally Inserted
36560 Tunneled, with port, <5yrs
36561 Tunneled, with port, >5yrs
36563 Tunneled, with pump
36565 Tunneled, requiring two catheters via two separate venous access sites, without port or pump (e.g., Tesio type catheter)*
36566 Tunneled, requiring two catheters via two separate venous access sites, with port(s)*Peripherally Inserted
36570 Tunneled, with port, <5 yrs
36571 Tunneled, with port, >5 yrs
*Note: The codes for repair, partial (catheter only)/complete replacement, or removal should be reported with a frequency of two if the procedure involves a multi-catheter device that has been placed via two separate access sites.
Repair
Catheter
Centrally or Peripherally Inserted
36575 Tunneled/non-tunneled, without port or pump
Device
Centrally or Peripherally Inserted
36576 Tunneled, with port or pump
Partial Replacement
Catheter
Centrally or Peripherally Inserted
36578 Tunneled, with port or pump
Complete Replacement
Catheter
Centrally Inserted
36580 Non-tunneled, without port or pump, through same venous access
36581 Tunneled, without port or pump, through same venous accessPeripherally Inserted (PICC)
36584 Non-tunneled, without port or pump, through same venous access
Device and Catheter
Centrally Inserted
36582 Tunneled, with port, through same venous access
36583 Tunneled, with pump, through same venous accessPeripherally Inserted
36585 Tunneled, with port, through same venous access
The complete replacement of a CVA device using the same venous access is reported using one procedure code (36580-36584); however, as noted in the CPT® 2004 manual, the removal of an existing CVA tunneled device and the placement of a new device, via a separate venous access site, should be reported using both procedure codes.
Removal (entire device)
Catheter
Centrally Inserted
36589 Tunneled, without port or pump
Device
Centrally or Peripherally Inserted
36590 Tunneled, with port or pump
Codes 36589 and 36590 describe the removal of a tunneled catheter device only. When a non-tunneled central venous device such as a non-tunneled central line or PICC line is removed, the procedure is considered inherent in the evaluation and management code reported for the clinical visit and is not separately reported.
Mechanical Removal of Obstructive Material
36595 Pericatheter (e.g., fibrin sheath), via separate venous access
36596 Intraluminal (intracatheter), through device lumen
Radiology practices should continue to use the radiological supervision and interpretation (RS&I) codes as cross-referenced in the parentheticals following codes 36595-36596, i.e., 75901 (Mechanical removal pericatheter obstructive material, RS&I) should be used with 36595, and 75902 (Mechanical removal intraluminal obstructive material, RS&I) should be used with 36596.
Repositioning
Catheter
36597 Under fluoroscopic guidance
Continue to report 76000 (Fluoroscopic guidance, up to 1 hr) for the fluoroscopic guidance used in repositioning a CVA catheter as directed in the cross-reference following code 36597. Do not report the newly established fluoroscopic guidance code associated with CVA.
Imaging
+75998 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 radiographic documentation of final catheter position) (List separately in addition to code for primary procedure)
+76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure)
Two new add-on codes (+75998, +76937) were established to report the imaging associated with central venous access when guidance is provided for "gaining access to the venous entry site or for manipulating the catheter into final central position." Code +76937 was established to report performance of ultrasound guidance for central venous access, and code +75998 was established to report fluoroscopic guidance of central access device placement, replacement or removal. Unlike the older fluoroscopic and ultrasound guidance codes, the guidance codes established for CVA are add-on codes, because the physician performing the primary procedure is the physician providing the ultrasound and/or fluoroscopic imaging services.
It is appropriate to use codes +76937 and +75998 for the same procedural encounter when both ultrasound and fluoroscopy are utilized, but all of the documentation requirements for each code (as noted below) must be fulfilled. A permanently recorded image for guidance (U/S and/or fluoroscopy) is required.
The fluoroscopic guidance code (+75998) includes the fluoroscopy used to maneuver the guide wire and subsequently the catheter into central venous position. The contrast injection through the access site and the mapping of the appropriate path are included. If spot films or other radiographic images are obtained in order to confirm final catheter position, they are also included. Note that it is appropriate to code for a formal extremity venography if it is performed from a separate venography access site and a separate interpretation is documented.
The descriptor for code +76937 explicitly states that this ultrasound guidance code is for "the evaluation of the potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry with permanent recording and reporting." The use of ultrasound to locate a vein or mark a skin entry point for a non-guided puncture is not considered an ultrasound-guided procedure and, therefore, does not meet the requirements to report +76937.
DISCLAIMER
The following are the coding opinions of the American College of Radiology (ACR). The recommendations referenced are those of members of the ACR Coding & Nomenclature Committee based on many years of work with the American Medical Association's CPT® Editorial Panel, and ACR's knowledge of the Centers for Medicare and Medicaid (CMS) policy. The final decision for coding of any procedure must be made by the physician, considering regulations of insurance carriers and any local, state or federal laws that apply to the physician's practice.