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Vascular access

  1. Default Vascular access
    Exam Training Packages
    My codes for the following procedure are

    76937-2659. Can anyone pls confirm whether this is correct.

    Procedure: Ultrasound-guided venous access and limited central

    History: 64 year old male with history of end-stage renal
    disease, hemodialysis dependent. The patient has known history of
    central venous occlusions, and currently receives dialysis via a
    tunneled, double lumen right groin dialysis catheter. Referred
    for PICC placement if possible or ultrasound guided venous access.

    Procedure: A preliminary
    ultrasound scan of the right upper arm was performed demonstrating
    patent questionable, diminutive brachial vein. With the patient
    in the supine position the right upper arm was prepped and draped
    in a sterile fashion and the skin and subcutaneous tissues were
    infiltrated with local Lidocaine. Under real time ultrasound
    guidance, the right brachial vein was punctured numerous times
    with a 21 gauge needle. A permanent sonographic recording was
    created for the patient's medical record. A 0.018 inch guidewire
    was inserted through the needle, however, would not advance
    further within the vein. Further attempts of venous access via
    the right arm were reported.

    Preliminary sonography of the left neck demonstrates a widely
    patent internal jugular vein, however, no external jugular vein is
    visualized. The left neck and upper chest were prepped and draped
    in usual sterile fashion. 1% lidocaine was administered to the
    skin and subcutaneous tissues. Using real-time sonographic
    guidance, the left internal jugular vein was punctured with a
    21-gauge needle. A permanent sonographic recording was created
    for the patient's medical record. Under fluoroscopic guidance, a
    0.018 inch wire was advanced through the needle, however, would
    not advance centrally within the chest. Exchange was made for the
    4-French micro-puncture introducer. Limited venography was then
    performed, demonstrating total central venous occlusion, with
    numerous, abnormal collaterals throughout the paracervical and
    intercostal regions.

    The 4-French micropuncture introducer was then left within the
    left internal jugular vein, to serve as central venous access for
    antibiotic therapy. The introducer was flushed with Hep-Lock
    solution and secured to the skin with sterile dressings.

    The patient tolerated the procedure well and no complications were
    encountered. Total fluoroscopy time was 1.0 minutes.
    Approximately 20 cc of Isovue 300 were used as intravascular

    Limited left central venography demonstrates complete occlusion at
    the origin of the brachiocephalic vein with numerous venous
    collaterals about paracervical and intercostal regions.

    Ultrasound and fluoroscopy guided placement of a 4 French
    micropuncture introducer through the left internal jugular vein
    without complication.
    Prabha CPC

  2. #2
    Default Vascular access
    Who are you billing for? The radiology codes would be 36556, 76937-26, and 77001-26 (the venogram is only performed to localize the veins to place the CVC so it is considered part of the CVC plcmt). The venipuncture codes are not billable separately either.
    Anita Elder, CIRCC, CPC, RCC

  3. Default vascular access
    Hi Anita,

    We bill for physician.My question is, in this case where the physician has punctured the jugular vein, he has not placed the tip of the catheter in subclavian, brachiocephalic,iliac vein or the superior or inferior vena cava.So,how can we code it as 36556? whereas the tip of a centrally inserted catheter should terminate in any one of these veins.
    Prabha CPC

  4. #4
    Default Vascular Access
    My apologies! I totally missed that crucial bit of information (some coder I am, huh??!!). From my understanding of an article in Clinical Examples in Radiology, if the cath stops in "midline" then you would use the PICC or CVC code with a 52 modifier. CPT 36000 looks like it would work as well however the RVUs are significantly lower and from the amount of work your physician provided I would want to obtain them the highest reimbursement possible (legally).
    Anita W, CIRCC, RCC, CPMA, CPC

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