complicated picc line removal hosp vs pro

treinemer

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I'm looking for a bit of clarification.

Our Hospital coder is saying we should bill this with 37197-74

37197
The physician places a needle into a blood vessel. A guidewire is threaded through the needle into the vessel and the needle is removed. A catheter is threaded into the vessel and the wire is extracted. The catheter, equipped with a grasping instrument, travels to the site of the foreign body typically using imaging guidance. The instrument grasps the foreign body, typically a fractured catheter, and retrieves it. The catheter is removed and pressure is applied over the puncture site to stop the bleeding.

My other PB coder and I do not think you can bill for a picc line removal in general but especially since it appears to be sutured to the patient. The most we think we might possibly be able to bill for is the fluoroscopy 76000-26

76000

A radiologist or other qualified health care provider supplies separate fluoroscopic monitoring of the body for up to one hour for procedures that do not include fluoroscopy as an integral component. This code is reported separately to describe the professional work component entailed in providing fluoroscopic monitoring. If formal contrast x-ray studies are done and included as a part of the procedure to produce films with written interpretation and report, fluoroscopy is already included and cannot be separately reported.


Any thoughts?
:confused:


Name of procedure: Attempted removal of PICC line under fluoroscopic guidance
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Assistant Dr______________*

Indication: This patient is a_____________with multiple medical problems who presented with cardiogenic shock. He had a PICC line placed. He then had open heart surgery. Subsequently, he developed leukocytosis and concern for systemic infection. An attempt was made to remove his PICC line, but that was not successful. He went to interventional radiology yesterday and the PICC line could not be successfully removed. Dr._______discussed the situation with me, and we agreed to repeat an attempt to remove the PICC line in the EP lab with higher quality fluoroscopy and with the option to use locking stylets if appropriate.
*
Description of procedure: The patient presented for the procedure transported from the ICU in his baseline intubated state, with his ICU nurse in attendance. His right arm was prepped and draped in sterile fashion. He is on multiple IV antibiotics currently, and those were continued.
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D and of the PICC line had been tied in a not; I was able to untie that not, and observe that this is a triple-lumen PICC catheter. I then advanced a Platinum Plus wire down the largest lumen of the PICC line, and under fluoroscopy we were able to observe that the Platinum Plus wire stopped when it met resistance about 1 inch from the distal tip of the PICC line, in the SVC. Simple traction on the PICC line at that point demonstrated that we were not able to pull the tip of the PICC catheter back. I then passed the Platinum Plus wire down one of the other 2 smaller lumens, and met resistance at the same exact site. When the wire was passed down the third lumen of the PICC line, I was able to advance it beyond the level of obstruction, and actually out the distal tip of the PICC line and into the right atrium and we confirmed that on fluoroscopy. Traction was again applied to the PICC line and Platinum Plus wire, but to no avail. The PICC line appears to be firmly adhered to the SVC about 1 inch proximal to its tip, likely by a suture placed by Dr. ______at the time of the open heart surgery. We had hoped that the suture had merely encircled the PICC line, pinning it to the SVC, and that it could be removed with adequate traction under fluoroscopy. However, the inability to pass the Platinum Plus wire through 2 of the 3 lumens of the PICC line suggests that the suture may actually puncture the side wall of the PICC line, obstructing those 2 lumens internally.
*
After further discussion of any other options we might have for transecting the PICC line in the intravascular space (and I had no suggestions that I felt afforded adequate safety for that maneuver), we aborted further attempts to remove the PICC line. Dr. _______ plans to take the patient to the operating room for open removal of the PICC line sometime within the next 24 hours.
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Estimated blood loss: Less than 10 mL
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Fluoroscopy: 10 minutes, 233 mGy
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Contrast: 0 mL
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Immediate competitions: None
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Conclusion: Unsuccessful attempt to remove PICC line under fluoroscopic guidance. The PICC line appears to be sutured to the SVC.
*
 
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There's a couple of ways to approach this, but I do have a couple of questions. The narrative states this is a triple lumen catheter. It's always been my understanding that placement of this type of catheter takes a fair amount of time, is done in an OR, the line gets sutured to the skin, and that it's tunneled. Am I correct in assuming the line is set up this way? The fact that the line is sutured to the skin and the patient had previously undergone surgery is what makes me think this is the case. I just wanted to clarify because there may be other options for coding that would be more appropriate.

On a side note, I assume this is not happening in an ASC or Outpatient Hosp, so a 74 would not be appropriate due to the POS.
 

treinemer

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Thank you for the reply!

It was not tunneled and was a temporary picc line. The patient was inpatient. I am a pro fee coder and the 74 was applied by the hospital coder on their charges.

Hope that helps!

Thanks! :)
 

coloradopa

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I think the original CPT is correct. Normally there is no CPT associated with a PICC removal. Usually the nurse pulls it out when ordered.

However, in this case something much different has happened.
1. The patient had a right arm triple lumen PICC
2. The patient went for open hear surgery
3. During the surgery a suture was placed through the Superior Vena then through the PICC fracturing the PICC
4. The patient developed leukocytosis and the ICU team tried to remove the PICC but couldn't
5. The PT went to IR and they couldn't either
6. IR went back using the cardiac cath lab thinking they could use a grasper to remove the fractured part but were unsuccessful (this is the part you are coding for)

Super coder describes 37197 as a 2013 replacement for two codes (one flouro code and one catheter removal)
"The added code is 37197 (Transcatheter retrieval, percutaneous, of intravascular foreign body [e.g., fractured venous or arterial catheter], includes radiological supervision and interpretation, and imaging guidance [ultrasound or fluoroscopy], when performed)."

This sounds exactly what was done and the -74 is appropriate for an unsuccessful procedure.
 
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