Anesthesiology Coding and Billing:
Central Venous Insertion

By Marcy Garuccio, ACS-AN, CANPC, CPMA, CPC
Reprinted with Permission, Medi-Corp, Inc.

Reviewing documentation of central venous catheters placement can be a challenge for coders and auditors.

Coders often see the indication noted on the paper anesthesia record, “insertion of CVP,” and they are instructed to code the appropriate code. While the documentation requirements listed by the AMA CPT guidelines are clear, many practitioners might not realize that their documentation is insufficient to support the coding and billing of the service. Unfortunately post audit findings are often how they learn their documentation is missing key necessary elements that would support the service.

AMA CPT guidelines detail the five categories of central venous catheter placement service. These are: insertion, repair, partial replacement, complete replacement, and removal.

The guidelines specify the document requirements for each category of service:

  • The terminal location
    Specifically, the terminal location of the central venous access catheter or device tip must be documented as subclavian, brachiocephalic (innominate) or iliac veins, the superior or inferior vena cava, or the right atrium.
  • How the device was inserted
    Devices may be inserted centrally via the jugular, subclavian, femoral vein, or inferior vena cava catheter entry site; or peripherally via basilic, cephalic, or saphenous vein entry site.
  • How the device is accessed
    Access may be gained external to the skin, via a subcutaneous port, or via a subcutaneous pump.

Without this documentation, the appropriate CPT code cannot be assigned. Hitting the mark with complete documentation of all the requirements including “tip termination site” is necessary.

In addition, the following key documentation elements are commonly reviewed in audits:

  • Informed consent obtained
  • Time out
  • Sterile technique deployed
  • Needle size
  • Type of line placed
  • Entry sites and structure
  • Tip termination site
  • Ultrasound usage with hard copy image storage and dynamic use notation
  • Placement start and time
  • Placed by (provider name)

From my years’ experience in managing and consulting with anesthesiology practices, I have learned that making the documentation requirements clear and easy to accomplish goes a long way towards achieving the goal of documentation to support coding and billing. Consider the following documentation tips for your team:

  • For paper charting: It would be recommended that the checklist be incorporated into the anesthesia record or provided as an additional document that would accompany the anesthesia documentation to the coders.
  • For practices utilizing EMR systems: As you develop or revise your template, ensure that the template prompts and assists the provider to capture all the necessary elements needed to document performance.

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