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2) Placement of a dual lumen temporary R femoral hemodialysis catheter placed.
Is a central line placement, CPT 36556, appropriate for these procedures referenced above?
In order to report a central line placement, MUST the provider state where the tip resides? Many times I do not see any documentation indicating where the tip of the device terminates. I see that ultrasound is used quite a bit to locate the vein, but no doc indicating where the tip of the catheter terminates.
Please help!
EXAMINATION: Central Venogram
CLINICAL HISTORY:
IV access requested. Central venous angiogram performed due to central venous occlusion.
FINDINGS:
Under ultrasound guidance, access was obtained into the basilic vein. Subsequently, under DSA
imaging left arm and central venous angiogram was performed.
Images demonstrate mature collaterals in the region of the distal subclavian vein extending into the neck
and along the chest wall. The collateral veins to communicate to the superior vena cava.
A 0.018 inch wire was threaded through the collateral veins into the superior vena cava. This wire was
utilized to advance the PICC line to the superior vena cava.
IMPRESSION:
THIS COMPLETE OCCLUSION OF THE CENTRAL VENOUS SYSTEM LEVEL OF THE MID TO
DISTAL RIGHT SUBCLAVIAN VEIN.
THERE ARE NUMEROUS COLLATERAL VEINS EXTENDING INTO THE NECK AND CHEST WHICH
DO COMMUNICATE TO THE SUPERIOR VENA CAVA. THE COLLATERAL WAS UTILIZED TO GAIN
ACCESS TO THE SUPERIOR VENA CAVA WHICH WAS SUBSEQUENTLY USED FOR PICC LINE
PLACEMENT.
My question is, can we code 36598 along with 36581 or is it part of the procedure?
Any help would be great..
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Since electronic medical records (EMR) have become prevalent, there has been concern whether documentation in the patient record accurately reflects medical necessity and the services provided. When I started working in the healthcare setting, we always told providers, “Not documented, not done.” Now, when I review a chart note, the question I
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