A Closer Look at CVCs

The 2019 CPT® manual included revisions and additions for central venous catheter (CVC) coding. In addition to these changes, the CPT® manual has also provided clarification for midline catheter coding.

The Basics

Central venous catheters provide means of drawing blood and administering substances into the patient’s large central veins. CVCs can also handle a larger volume of fluids than a peripheral IV line. To be considered a central venous catheter, the catheter tip must be positioned in the subclavian vein, brachiocephalic (innominate) vein, iliac vein, superior or inferior vena cava, or the right atrium.

CVCs are either centrally inserted or peripherally inserted. A centrally inserted central venous catheter is inserted into the subclavian vein, jugular vein, femoral vein, or inferior vena cava. A peripherally inserted central venous catheters (PICC) is inserted in any other vein, such as the basilica or cephalic veins.

Midline catheters are not considered to be CVCs. By definition, a midline catheter would terminate in a peripheral vein, rather than a central vein.

Centrally inserted CVCs can be tunneled or non-tunneled and may be connected to a port or pump. PICCs are non-tunneled and may be connected to a port.

CVC Insertion

The codes for CVC procedures are defined in terms of:

  • The type of procedure (insertion, replacement, etc.)
  • The type of device (centrally vs peripherally inserted, tunneled vs non-tunneled, etc.)
  • The patient’s age (younger than 5 years versus 5 years or older)
  • The use of imaging guidance (PICC codes only)

The CPT® manual defines insertion as “placement of catheter though a newly established venous access” to distinguish it from replacement, in which a new catheter is inserted though the same access site. CVC insertion of a centrally inserted CVC is reported with codes 36555-36566. The table below provides a summary of the codes.

Table 1: CENTRALLY INSERTED CVC INSERTION

  Nontunneled Tunneled
w/o port or pump w/ port w/ pump
Insertion (< 5 years) 36555 36557 36560 36563
(≥ 5 years) 36556 36558 (1 access) 36561 (1 access)
36565 (2 accesses) 36566 (2 accesses)

Fluoroscopic (77001) or ultrasound (76937) guidance is not included in code 36555-36566 and should be reported separately.

PICC insertion is reported with codes 36568-36573. The table below provides a summary of the codes.

Table 2: PERIPHERALLY INSERTED CVC INSERTION

w/o port or pump, w/o imaging w/o port or pump, w/ imaging w/ port
36568 36572 36570
36569 36573 36571

Notice there are codes that specifically include all associated imaging guidance (36572, 36573). If imaging guidance is used, but position of the catheter tip cannot be confirmed, modifier 52 should be applied to code 36572 or 36573. If imaging guidance is not used, the non-imaging placement codes should be reported (36868-36869).

CVC Repair, Replacement, and Removal

CVC repair is defined by the CPT® manual as “fixing device without replacement of either catheter or port/pump.”

CVC repair is reported with code 36575 (without port) or 36576 (with port) for both centrally inserted and peripherally inserted CVCs. Some catheters, such as Tesio-style catheters, have 2 catheters. Repair of both catheters would be reported with 2 units of the repair code.

Partial replacement refers to replacing a catheter that is connected to a port or pump without replacing the port or pump. Code 36578 is reported for partial replacement of both centrally inserted and peripherally inserted CVCs. Report 2 units of 36578 is both catheters of a Tesio-style device are partially replaced.

Complete replacement of a CVC not connected to a port or pump is a fairly simple procedure. It is reported with codes 36580-36581 for centrally inserted catheters. For PICCs, it is reported with code 36584, which includes all associated imaging guidance and documentation and S&I required.

Complete replacement of a CVC with an implanted port or pump requires replacement of the port or pump as well as the catheter. This procedure is reported with codes 36582-36583 for centrally inserted catheters or 36585 for PICCs.

For a Tesio-style device, complete replacement would be reported with 2 units of the replacement code.

The catheter will be removed when it is no longer needed or when removal is medically indicated due to infection or other reason. There is no code for removal of non-tunneled catheters, but this service can be reported with a low-level evaluation and management (E/M) code if documentation meets the E/M criteria. Removal of a tunneled CVC without a port or pump is reported with code 36589. For catheters with a port or pump, report the removal with code 36590, which includes removal of the catheter as well as the port or pump. Removal of Tesio-style devices should be reported with 2 units of the removal code.

Report fluoroscopic or ultrasound guidance separately with all of the codes discussed in this section except for code 36584.

Other CVC procedures include repositioning (36597), contrast injection (36598), declotting (36593), and mechanical removal of obstructive material (36595, 36596, 75901, 75902). We will not discuss these procedures in detail in this article.

Midline Catheters

As mentioned before, midline catheters are not considered central venous catheters by definition. Prior to 2019, CPT® Assistant and Coding Clinic for HCPCS provided instructions to assign a PICC placement code for the placement of a midline. The 2019 CPT® manual contains new guidance that instructs you to use the venipuncture codes 36400, 36405, 36406, and 36410 for midline insertion.

36400 Venipuncture, younger than age 3 years, necessitating the skill of a physician or other qualified health care professional, not to be used for routine venipuncture; femoral or jugular vein

36405 Venipuncture, younger than age 3 years, necessitating the skill of a physician or other qualified health care professional, not to be used for routine venipuncture; scalp vein

36406 Venipuncture, younger than age 3 years, necessitating the skill of a physician or other qualified health care professional, not to be used for routine venipuncture; other vein

36410 Venipuncture, age 3 years or older, necessitating the skill of a physician or other qualified health care professional (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture)

Coding central venous catheter procedures can seem overwhelming. Take the time to carefully read the report to determine what procedure was done and review the definitions and guidelines in the CPT® manual. With the exception of exceptions, all the information you need will be right in front of you.

- Article by Coding Strategies® Staff