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Code This!

Scenario Week of March 01, 2012:
View Current Scenario

Ultrasound guidance for venous access
Tunneled port (age>5 years) placement
Fluoroscopic guidance placement

Clinical History
Vascular port placement requested for chemotherapy access for this 57-year-old male patient with non-Hodgkin’s lymphoma

Fluoroscopy Time: 2.6 minutes

Procedure Description
Intravenous sedation was administered. 3 mg Versed and 100 mcg Fentanyl IV. Vital signs and sedation monitored by nursing staff under interventional radiologist’s supervision. Limited jugular ultrasound documented jugular vein patency.

The right neck and upper chest were prepped and draped in the usual sterile fashion. 10:1 volume mixture of 1% lidocaine without epinephrine buffered with 8.4% bicarbonate solution was used for local anesthesia. Under ultrasound guidance, right internal jugular venotomy was made with a micropuncture needle. Permanent copy of the image documenting the vein was entered into the patient’s record.

Under fluoroscopic guidance, the micropuncture needle was exchanged over the guidewire for the micropuncture sheath. Catheter length measured with the 0.018 guidewire. Micropuncture sheath saline locked. A subcutaneous pocket was created for the port reservoir over the right anterior chest using a combination of sharp and blunt dissection. The pocket was liberally irrigated with 1 gm Ancef solution. Catheter was subcutaneously tunneled from the right anterior chest pocket to the right internal jugular venotomy site. Catheter was cut to length. Micropuncture sheath exchanged over guidewire for the peel-away sheath and advanced under fluoroscopic guidance to the high right atrium. Peel-away sheath removed. Port aspirated and flushed adequately. Port reservoir secured with a single 2-0 PDS II suture around the catheter. The right anterior chest incision was closed with 4-0 Vicryl interrupted suture, a running 4-0 Monocryl subcuticular suture, and Dermabond. Right internal jugular venotomy site closed with Dermabond. Port accessed and then heparin locked with 100:1 heparin solution. No immediate complication.


  1. Ultrasound guided right internal jugular venotomy.
  2. 6 French single-lumen Bard PowerPort placed. Tip in the high right atrium. Port left accessed, heparin locked, and ready for use.

Diagnosis Codes
V58.81 Fitting and adjustment of vascular catheter

202.80 Other lymphoma, unspecified site

Procedure Codes
36561 Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years and older

76937 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 (List separately in addition to code for primary procedure)

77001 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 interpretations, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure)

The instructional notes in ICD-9-CM for supplementary classification of factors influencing health status and contact with health services (V01–V91) indicate the use of codes from this category are appropriate when a patient with a known disease is seen for specific treatment of the disease and indicates the reason for the visit.

ICD-9-CM index directs the coder to 202.8x for non-Hodgkin’s type with the fifth digit utilized for unspecified site since this note does not indicate the specific area of disease.

CPT 2012 instructions indicate “to qualify as a central venous access catheter or device, the tip of the catheter/device must terminate in the subclavian, brachiocephalic (innominate) or iliac veins, the superior or inferior vena cava, or the right atrium.” Based on the documentation, this procedure qualifies as a central venous access device. In addition, CPT code 36561 would be selected as the device is described as tunneled underneath the skin and the patient is over five years of age.

Ultrasound guidance is used for access site, and image documentation is provided within the patient record. Fluoroscopy is used for placement of the access device. In the Principles of CPT Coding, page 342 (6th edition), clarification is made on the use of fluoroscopy: imaging modality can be reported in conjunction with other imaging during a procedure with a specific example cited as insertion of central venous catheter using both ultrasound and fluoroscopic guidance. Furthermore, both imaging codes are classified as add-on codes by CPT and there are no CCI edits in place that would require the use of a modifier.

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