Radiology Coding Alert

Many professional coders report confusion about how to code implantation of venous access ports (36533), as opposed to placement of central venous catheters (36488-36491). Although the two procedures are very different, coders indicate that they often have a hard time distinguishing what code to use for each service.

Part of the challenge is recognizing what each procedure entails and what types of devices are used. In addition, coders must work closely with interventional radiologists to ensure that documentation clearly reflects the level of work conducted.

Learning the differences between the procedures also is crucial because they are reimbursed at highly disparate levels, coding experts note. For instance, 36533 has 10.28 relative value units (RVUs), while 36489 is reimbursed at less than a third of that, at 3.13 RVUs.

How to Code Central Venous Catheters

Generally speaking, the less complex of the two procedures is the placement of central venous catheters, often referred to as central or peripherally inserted central catheter lines (PICC), says Kathleen Mueller, RN, CPC, CCS-P, an independent coding and reimbursement consultant and educator based in Lenzburg, Ill. To be classified as a central line, the catheter must be placed ultimately in the subclavian, brachiocephalic, innominate or iliac veins, or the junction where one of these veins joins the superior or inferior vena cava. This category of service also includes placement of triple-lumen catheters and temporary subclavian or femoral venous lines, such as those used in intensive care unit patients or for temporary dialysis access. These catheters are intended for short- or medium-term use.

Codes used for central venous catheter placement are:

36488 placement of central venous catheter
(subclavian, jugular or other vein)(e.g., for central
venous pressure, hyperalimentation, hemodialysis, or
chemotherapy); percutaneous, age 2 years or under;
36489 ... percutaneous, over age 2;
CPT 36490 ... cutdown, age 2 years or under; and
36491 ... cutdown, over age 2.

Coding for this procedure depends on the age of the patient and the approach to the vein, according to Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., an Atlanta-based firm that supports 1,000 radiologists and 350 physicians from other specialty areas. Codes 36488 and 36489 are percutaneous codes, but 36490 and 36491 are identified as cutdown codes, in which the selected vein can be seen through the incision. In addition, 36488 and 36490 are assigned for procedures on patients 2 years old or younger depending on the approach, but 36489 and 36491 are reported for patients older than 2.

During the procedure, the physician places the percutaneous PICC line or temporary catheter by piercing the skin and positioning the device directly into the vein, Parman explains.

How to Code Venous Access Ports

Implantation of a venous access port is a more complicated procedure, requiring the interventionalist to make at least two incisions and create a subcutaneous tunnel to place the device beneath the patients skin. Coders would assign 36533 (insertion of implantable venous access device, with or without subcutaneous reservoir) for this service. In other words, this procedure means the incisions were made on and below the skin, and the catheter was tunneled through subcutaneous tissue into the vein, Mueller says.

Code 36533 may be assigned when a venous access device is implanted either partially or completely, Parman says. Completely implanted devices (e.g., Huber, Angiocath) have no external site for direct catheter access and include a subcutaneous reservoir. Partially implanted devices (e.g., Hickman, Broviac) do not have subcutaneous reservoirs but exhibit a visible external site that is remote from the venous entry site.

These access ports are intended typically for long-term use, and indications include dialysis, chemotherapy or other long-term therapy requiring central venous administration.

The keyword that coders should look for to identify this service is tunneling, Parman says. Although some interventionalists may point out that a short subcutaneous tract is also formed when a PICC line or triple-lumen catheter is placed, that is very different from the intentional surgical channel that the interventionalist creates with a 36533.

Note: CPT lists two related codes that may be used with 36533: 36534 (revision of implantable venous access device, and/or subcutaneous reservoir) and 36535 (removal of implantable venous access device, and/or subcutaneous reservoir). Neither, however, may be assigned in conjunction with 36488-36491.

Interventionalist Must Provide a Clear Description

Coders say billing problems arise largely because the radiologist performing the procedure often neglects to give the coders enough information to help them determine which service was provided. In many instances, physicians will note the brand name of the device in the patient record but not describe precisely what was done during the procedure, says Parman.

Parman points out, however, that coders are not clinical experts and may not know the differences between brands of catheters, or whether they are implanted subcutaneously. While coders must understand the different codes that are available, physicians should become more aware about how they communicate with the coding and billing staff, she says. Even though physicians know what procedure they performed, they need to be very clear in their documentation and stop using only the catheters brand name to indicate the procedure. Coders should not assign codes based upon the name of the device used but on the technique of implantation.

When the physician properly documents the procedure, coders will be able to read through the procedure section of the operative report to find out how the catheter was inserted. Looking at the top of the operative report is not enough, Mueller points out. Typically it will say, insertion of Groshong or insertion of Hickman. Based on this description, a physician may understand what was done, but it wont be enough detail for the coder. After reading the procedure section, however, the coder should be able to identify how the catheter actually was put in the body, and then he or she can proceed to bill without further difficulty.

Because of the ongoing confusion related to these two codes, insurance carriers often believe that the procedures may have been reported incorrectly and question claims containing these codes. When they send back the explanation of benefits, they may indicate that the claim is pending review and, for clarification, request the operative report, explains Mueller. Usually, they are concerned that 36489 has been coded incorrectly as 36533, so they want to ensure the interventionalist actually inserted a tunneling device and not a direct central line.

Diagnosis Coding Must Support Necessity

Coders also must ensure that they assign the proper diagnosis code for each procedure. In some cases, the correct diagnosis code will not correlate with the primary condition from which the patient is suffering. For instance, implantable venous access ports are placed typically in patients undergoing chemotherapy. The placement of the device is not related directly to the cancer, but to the fact that the medication is toxic to the veins. In other instances, the device may be required because the patient may have poor veins.

Therefore, the relevant cancer diagnosis code would not be assigned. Instead, coders would report 459.89 (other specified disorders of the circulatory system; other), which reflects the physicians documentation for implanting the device. The primary diagnosis (e.g., cancer) also may be included with the claim, although it is not necessary. Local carriers also may have specific guidelines that coders must follow.

Mueller notes that codes 36488-38491 sometimes will be denied because medical necessity has not been indicated. For example, a patient may become debilitated during an interventional procedure, and the radiologist inserts a central venous catheter. If the diagnosis code accompanying 36488 or 36489 describes the reason for surgery, not the reason why the catheter was inserted, the claim may be denied.

In addition, coders should be aware that if the 36533 or 36488-36491 is being performed during a global period of the primary procedure, modifier -79 (unrelated procedure or service by the same physician during the postoperative period) must be added. Unless the procedure was planned preoperatively, modifier -58 (staged or related procedure or service by the same physician during the postoperative period) would be attached instead.

According to the national Correct Coding Initiative, codes 36488-36491 will be bundled into 36533 when either of these codes is billed with 36533. Only one of the codes in the pair will be allowed unless documentation indicates that the two services represent different sites or sessions. If that is the case, modifier -59 (distinct procedural service) should be used.