Forum topic

 You can search this site to find many previous dicussions on charges. Basically you need to document what devices, supplies, equipment, etc that is being used through whatever system yoour facility is using. This will help to allocate money at budget time. But for inpatients, these "charges" will NOT result in additional money being paid to the hospital. Medicare DRGs, and private insurance companeis now pay by a flat fee that is based on the diagnosis - DRG is diagnosis related groups. This is different for oupts though. Lynn

 Hello new nurse to vascular access! There is much confusion about billing structure for PICCs, Midlines and USGPIVs and while it can be quite complicated I hope to add some clarity based on an inquiry and response from the Centers for Medicare and Medicaid (CMS).

As Lynn said you cannot get reimbursement for the placement of peripheral catheters. The issue of ultrasound needle guidance for catheter placement is a little more murky and so I will focus on PICCs and Midlines. My question to you is if a patient is difficult IV access DIVA in the first place and needing reliable access, would it not be better to go ahead and place a midline?

Here is the question and response from CMS. Nancy Moureau, PICC Excellence

CPT Code Validation for Midlines

Posted on www.PICCExcellence.com: December 5th, 2014 by Sally/Nancy

There have been some questions regarding appropriate reimbursement coding for Midline catheters. PICC Excellence removed Midline CPT Code information pending the validation of this information. It now appears midline catheters will continue to use the same PICC codes for percutaneous insertion location even though the terminal tip of the catheter does not enter the central vasculature as you can see in the response below.

Based on a communication inquiry with CMS for CPT code validation, here is the response:

From a CPT coding perspective and based solely upon the information provided in your inquiry, the recommended to report codes 36568, Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; under 5 years of age, or 36569, Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; age 5 years or older, for PICC insertion for midline placement has not changed.  As stated in CPT Changes 2004 when the codes were created, “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. The venous access device may be either centrally inserted (jugular, subclavian, femoral vein or inferior vena cava catheter entry site) or peripherally inserted (eg, basilic or cephalic vein). The device may be accessed for use either via exposed catheter (external to the skin), via a subcutaneous port or via a subcutaneous pump.”  These guidelines and the reporting of PICC insertion codes for midline placement are still in place.

Following is the Relative Value Scale (RVS) Update Committee’s (RUC) rationale for classifying these codes.

History:  In the second, Five-Year Review of the RBRVS, CPT code 36489 Placement of central venous catheter (subclavian, jugular,or other vein) (eg, for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy); percutaneous over age 2 was increased from 1.22 to 2.50 work relative value units, as a rank order anomaly existed between this service and CPT code 36010 Introduction of catheter, superior or inferior vena cava (work RVU = 2.43).  In addition, a number of other services in the family were identified as potentially mis-valued.  CPT codes 36533, 36534, and 36535, which described the insertion, revision, and removal of implantable venous access device, and/or subcutaneous reservoir were considered by the RUC, but the RUC noted that the descriptor stated “and/or subcutaneous reservoir.”  The RUC stated that there are multiple venous access capabilities for varying disease processes which require varying degrees of work for different venous access devices.  Therefore, the RUC agreed to refer this issue to CPT to create specific codes that are more descriptive of the actual service being performed.

The CPT Editorial Panel created a Central Venous Access Procedures Workgroup, who worked on this issue for nearly two years.  The results of their efforts are a section in CPT for Central Venous Access Procedures that describes these services in five categories:

1. Insertion (placement of catheter through a newly established venous access)

2. Repair (fixing device without replacement of either catheter or port/pump, other than pharmacologic or mechanical correction of intracatheter or pericatheter occlusion (see 36535 or 36536 for those procedures – catheter clearance)

3. Partial replacement of only the catheter component associated with a port/pump device, but not entire device.

4. Complete replacement of entire device via same venous access site (complete exchange).

5. Removal of entire device.

Work Relative Value Recommendations

Five specialties participated in a survey of the physician work involved in this family of services, including general surgery, radiology, interventional radiology, pediatric surgery, and anesthesiology.  The specialties then met to review the survey results and develop consensus recommendations.  At the April RUC meeting, these specialties met with a pre-facilitation committee on several occasions to further refine their recommendations to the RUC.  The specialties did note that the surveys were problematic.  For example, there was not a difference in work indicated for pediatric patients.  The specialty believes this is due to few pediatric surgeons participating in the survey.  The RUC agreed that a difference should be reflected in the final RUC recommendations.  The RUC reviewed alternative ways to value codes, such as the use of intraservice work per unit of time (IWPUT), and steps to ensure appropriate rank order and relativity within the family of services.

In developing the recommendations, the specialties arranged the CPT codes into families of similar services, based upon the original code which was replaced.  An anchor code was selected based upon frequency, or the base code, or upon a direct cross-walk.  The specialties reviewed the IWPUT of the survey results and used this IWPUT as a general guide to each family of codes.  The IWPUT was used as a check of the value determined by the survey and of the relationships within a family and between types of codes (eg, pediatric versus adult codes).

The RUC agreed with the specialties’ presentation, as the pre-facilitation committee had significant input into the final work relative value recommendations.

 Vignette

A 62 year-old male requires long term antimicrobial therapy. A peripherally inserted central venous catheter (PICC) is inserted. Local lidocaine anesthesia is administered. The basilic vein is punctured and a guidewire passed centrally. The peripherally inserted central venous catheter is cut to appropriate length and then placed. The catheter is sutured in position and dressed in standard fashion, and flushed or attached to IV infusion fluids.

Please note that CPT Information Services is unable to address the coding practices of healthcare facilities.  Eligibility for payment, as well as coverage policy, is determined by each individual insurer or third party payer, therefore, you may wish to contact your local third party payer for specific reporting requirements.

Thank you for your inquiry and we hope that this information is of assistance to you.

 Sincerely,

 CPT Education and Information Services