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Wiki Documention for PICC line placement

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birky

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I have a physician that doesnt document in his reports where where venous access was made for a PICC line placement and states it isnt required, I think it is necessary and need supporting documentation to provide this physician. The following is an example for the report:



The left arm was prepped and draped in sterile fashion. Buffered 2% lidocaine was injected for local anesthesia. Under ultrasound guidance, venous access was made and guidewire placed. The peel-away sheath was placed over the wire. A 5-French PICC line catheter was cut to a 48- cm length and advanced under fluoroscopy and maneuvered into the superior vena cava.

The final position in the distal superior vena cava was confirmed with a spot image.


IMPRESSION:
SUCCESSFUL ULTRASOUND AND FLUOROSCOPICALLY GUIDED LEFT ARM PICC LINE INSERTION WITH THE TIP IDENTIFIED IN THE DISTAL SUPERIOR VENA CAVA

Thank for your assistance with this question.
 
birky said:
I have a physician that doesnt document in his reports where where venous access was made for a PICC line placement and states it isnt required, I think it is necessary and need supporting documentation to provide this physician. The following is an example for the report:



The left arm was prepped and draped in sterile fashion. Buffered 2% lidocaine was injected for local anesthesia. Under ultrasound guidance, venous access was made and guidewire placed. The peel-away sheath was placed over the wire. A 5-French PICC line catheter was cut to a 48- cm length and advanced under fluoroscopy and maneuvered into the superior vena cava.

The final position in the distal superior vena cava was confirmed with a spot image.


IMPRESSION:
SUCCESSFUL ULTRASOUND AND FLUOROSCOPICALLY GUIDED LEFT ARM PICC LINE INSERTION WITH THE TIP IDENTIFIED IN THE DISTAL SUPERIOR VENA CAVA

Thank for your assistance with this question.
Click to expand...


IMO, this documentation is adequate for coding a PICC, with the exception of the ultrasound guidance. I would code this:
36569 (or 36568 if younger than 5) and 77001

HTH :)
 
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