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Code This!

Scenario Week of January 24, 2013:
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Assign the correct ICD-9-CM and ICD-10-CM diagnosis and CPT 2013 procedure codes for the following outpatient coding scenario:

History: : 68-year-old female with chronic renal failure is seen for VAD placement

Procedure: Ultrasound was used to reveal a patent right subclavian vein. The region was anesthetized and access to the right subclavian vein was gained with a 19 gauge needle. A guidewire was advanced into the venous system. The subcutaneous tunnel was anesthetized with Lidocaine with epinephrine. Incisions were made at the venotomy and the chest wall exit site. A 24 cm 14-FR Ash Split catheter was advanced from the chest wall exit site to the venotomy site with the supplied tunneling device.

Serial fascial dilation was then performed over a previously placed guidewire with final placement of a 15-FR peel-away sheath into the subclavian vein. The dilator and wire were removed followed by placement of the Ash Split catheter into the venous system. The catheter was positioned at the cavo-atrial junction under fluoroscopy. The peel-away sheath was removed. The venotomy was closed with a single 3.0 Vicryl suture followed by Dermabond tissue adhesive.

Assign the correct ICD-9-CM and CPT 2013 procedure codes for these physician services.

ICD-9-CM Diagnosis Code

V58.81 Fitting and adjustment of vascular catheter

Rationale: In this instance, the reason for the encounter was not treatment for the patient’s chronic renal failure, but simply for placement of the vascular access device for future treatment. Therefore, it is not appropriate to list renal failure as the diagnosis as that was not treated at this encounter. There is no information that this is a catheter for renal dialysis – this is a standard vascular access device.

CPT Procedure Codes

36558 Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older

77001–26 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 radiographic documentation of final catheter position) (List separately in addition to code for primary procedure)

Rationale: CPT codes in the venous access device section are chosen based on several different attributes. The first attribute to determine is whether it is an initial placement, a repair, a replacement, a removal, or a repositioning. Based on the documentation it is determined that this is an initial insertion or placement. The next important attribute is whether it is tunneled or non-tunneled. This documentation has several indications that this is a tunneled device. The third attribute to consider is whether a port or pump is included with the device. In this instance, there is no port or pump included. A fourth attribute reviewed is whether it is a centrally inserted catheter or a peripherally inserted catheter. This documentation refers to the subclavian vein, guiding us to a centrally inserted catheter. Finally, age of the patient plays a role in code selection. Patients younger than age 5 can pose a different risk and create a different set of circumstances for physicians, and therefore have their own codes in many instances. The patient in this example is greater than 5 years of age. The 68-year-old patient in this example has a tunneled, centrally inserted central venous catheter without a port or pump. This leads the coder to code 36558.

There is also mention of two imaging procedures in the documentation. Ultrasound was used early in the procedure for gaining entry to the right subclavian vein. Ultrasound can be coded separately with 36558 using code 76937. However, when examining code 76937, it is quite clear that in order to separately report this service, there are certain documentation requirements. Selected vessel patency must be documented, as well as permanent recording and reporting of the ultrasound service and real-time visualization of the vascular needle entry. As there is little documentation of the ultrasound services there is not enough in this record to report the services separately. If perhaps there is a separate ultrasound report, there may be the option to bill the ultrasound services from that record. There is also a documented fluoroscopy service for final catheter manipulation toward the end of the report. Physician supervision and documentation is reported for that service using 77001–26.


CPT 2013
ICD-9-CM 2013
ICD-10-CM 2013

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