Insertion of Tunneled Catheter ASDIN Coding University 1

Primary & Secondary As with other procedures there are primary codes that are used in virtually every tunneled catheter placement procedure and secondary codes for procedures that are used only when exceptional events occur We shall consider these separately 2

Primary Codes Used in virtually every TDC placement procedure 3

Ultrasound Guidance The code for ultrasound guided cannulation when inserting a tunneled catheter is The descriptor for this code is - ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting 4

Requirements for Code Usage As indicated in the descriptor, use of requires that an image be recorded and made part of the permanent record As the descriptor states, this requires concurrent realtime ultrasound visualization of the vascular needle entry Additionally, the record should include a narrative documented description of the localization process for which the guidance was utilized 5

Restrictions for Code Usage code should not be used in cases where the vein is only examined by ultrasound and the cannulation is not actually ultrasound guided (real- time) is an add-on code and requires that the primary procedure also be listed, in this case that would be for catheter insertion 6

Fluoroscopic Guidance The code for fluoroscopic guidance used in connection with the placement of a central venous device is The descriptor for this code is - fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiologic documentation of final catheter position) 7

Code Includes Angiographic Studies As indicated, also includes any necessary contrast injections through the access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of the final catheter position It is possible to have an angiographic study qualify as a separate procedure if it is done by selective catheterization or if it is done from a separate access site In such an instance, a 59 modifier should be attached to the code to indicate that it is a separate procedure 8

Add-On Code The code is an add-on code and requires that the primary procedure also be listed, which would be the code for catheter insertion The code cannot be used with which is the code for using a target device for cannulation 9

Catheter Insertion The code used for the actual catheter insertion is The descriptor for is – insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump, over 5 years of age This code is for the procedure in which a single tunneled catheter is inserted 10

Double Catheter If two structurally separate catheters are inserted into two separate venous sites, the appropriate code would be The descriptor for this code is - insertion of tunneled centrally inserted central venous access device, requiring two catheters via two separate venous access sites, without subcutaneous port or pump The descriptor indicates that if is to be used, the two catheters must be inserted via separate access sites A dual catheter inserted through a single venous access site would not qualify 11

Secondary Codes Used when an unusual circumstances arises 12

Fluoroscopic Guidance for Needle Placement In some instances the internal jugular vein cannot be cannulated directly and a device such as an angioplasty balloon or a snare might be inserted and used as a target for cannulation with fluoroscopic guidance for the cannulation needle placement The recommended code for this procedure is The descriptor for this code is - fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) 13

77002 Includes Angiography also includes any necessary contrast injections through the access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of the final catheter position It is possible to have an angiographic study qualify as a separate procedure if it is done by selective catheterization or if it is done from a separate access site In such an instance, a 59 modifier should be attached to the code to indicate that it is a separate procedure 14

77002 Restrictions The code is not an add-on code It is a column 2 code to (catheter insertion) It can be used with but does require a modifier, in the instance described here, a 59 modifier would be appropriate It is a column 1 code to and the two are mutually exclusive (can’t be used together) 15

Venous Angioplasty If a significant stenosis is encountered when a tunneled catheter is being placed and is treated with angioplasty, then the appropriate codes for that procedure should be recorded The code for venous angioplasty is 35476, its descriptor is – transluminal balloon angioplasty, venous Code describes the radiological supervision and interpretation, its descriptor is - transluminal balloon angioplasty, venous, radiological supervision and interpretation If a venous angioplasty is performed, then the use of (or 77002) will require a 59 modifier since this would combine the use of a diagnostic and a therapeutic RS&I code 16

Aborted Cannulation Site If, after cannulating and examining a vein angiographically, it is decided to abandon that site and move to another, additional codes may be warranted to account for the work that was done At the aborted site this often includes: – Ultrasound guidance for cannulation – Cannulation – Fluoroscopy and angiography These procedures are coded differently since a catheter is not inserted at the aborted site 17

Ultrasound Guidance for Cannulation The recommended code for ultrasound guided cannulation of an aborted site is The descriptor for this code is – ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting This is an add-on code and must be used with a primary code, in this instance that code would be (next slide) Image documentation in the medical record is required 18

Cannulation of Aborted Site Unlike the usual situation, the ultrasound guidance code, , does not include the cannulation The code is recommended for cannulation of an aborted site The descriptor for this code is - venipuncture, age 3 years or older, necessitating physician's skill (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture) 19

Fluoroscopic Guidance With Aborted Site The use of the code can be used only for the site that is actually used to insert the catheter With an aborted site, the coding of the fluoroscopy and angiography is dependent upon the specific vessel involved 20

Angiogram of Aborted Site The internal jugular vein is often involved with an aborted site If this is the case and an angiogram of that vein was performed, then the code would be warranted The descriptor for is - venography, venous sinus (e.g., petrosal and inferior sagittal) or jugular, catheter, radiological supervision and interpretation Additional codes might be warranted if additional veins are involved When the code is used with 36410, it is a column 1 code and is a column 2. In this instance, while the two can be used together, the column 2 code, 36410, would require a 59 modifier The medical necessity for these procedures should be clearly documented in the patient record and in the recorded images 21

Important Note This document is for informational purposes only and should serve as a guideline for appropriate coding. The ultimate responsibility for correct coding /documentation remains with the provider of service. ASDIN makes no representation, warranty, or guarantee that this compilation of information is error-free, nor that the use of this guide will prevent differences of opinion or disputes with CMS or any other carrier. ASDIN will bear no responsibility or liability for the results or consequences that may grow out of the use of this guidance. 22