Anesthesia Coding Alert

Question: The provider’s documentation included the following procedure note for an inpatient service provided at 14:12 during an anesthesia case that ran from 13:59 to 17:12.

The indication for this procedure is intravenous access and hemodynamic monitoring during surgery. A time-out was completed, verifying correct patient, procedure, site, positioning, and equipment. The 76-year-old patient was placed in a position appropriate for non-tunneled central line placement based on the vein to be cannulated; prepped and draped in sterile fashion. 1 percent lidocaine used to anesthetize surrounding skin. A triple lumen 9-French Cordis catheter was introduced into the right internal jugular vein using Seldinger’s technique under ultrasound guidance, with the tip terminating in the subclavian vein. Please see attached ultrasound image and description of ultrasound guidance used during the procedure. The catheter was threaded smoothly over the guide wire and appropriate blood return was obtained. Each catheter lumen was evacuated of air and flushed with sterile saline. The catheter was then sutured to the skin and a sterile dressing applied. The patient tolerated the procedure well; no blood loss, no complications.

What procedure codes should the anesthesiologist report for the line placement?

AAPC Forum Participant

Answer: In this case, the anesthesiologist should submit two codes in addition to the code for anesthesia services. The central venous catheter (CVC) was non-tunneled and centrally inserted, and the patient was older than 5, so report 36556 (Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older) for the central line placement.

Imaging: Because ultrasound guidance was used, include add-on code +76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites … with permanent recording and reporting …) and append modifier 26 (Professional component).

Key: Even if the anesthesiologist did not indicate separate placement of a central line, this procedure note is sufficient documentation for reporting the insertion of a CVC for intravenous access and monitoring during the surgery. While monitoring is included in the base value for anesthesia, placement of a central line is not and may be reported separately.

Don’t miss: CPT^® guidelines outline the requirements needed to qualify the line as a central venous access catheter; thus, documentation should indicate:

The terminal location: The central venous access catheter or device tip must be documented as in the subclavian, brachio­cephalic (innominate) or iliac vein, superior or inferior vena cava, or right atrium.

How the device was inserted: Central (via the jugular, subclavian, femoral vein, or inferior vena cava catheter entry site) or peripheral (via basilic, cephalic, or saphenous vein entry site) insertion.

How the device is accessed: Either via an exposed catheter (external to the skin), a subcutaneous port, or a subcutaneous pump.

Without this documentation, you cannot assign the appropriate CPT^® code. Hitting the mark with complete documentation of all the requirements including the tip termination site is necessary, as payers may be looking for this detail in the documentation.