Anesthesia Coding Alert

Question: The anesthesiologist placed a central venous catheter during a procedure. What documentation will help justify coding the placement?

Minnesota Subscriber

Answer: Include 36555 (Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age) or 36556 (... age 5 years or older) on the claim, according to the patient's age.

The more information your physician's documentation includes, the better. Details should include the reason for the procedure, the use of informed consent, the patient's position during the procedure, skin preparation, local anesthetic or ultrasound used, insertion site, and sutures and dressing applications used.