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:
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:
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:
Link to the original article: https://libmaneducation.com/anesthesiology-coding-and-billing-central-venous-insertion/?utm_source=coders-corner&utm_medium=email&utm_campaign=LEI2023&utm_content=LE-Coders-Corner-Eblast-FRI-8-25-2023-6am