We will dedicate our next few posts to explaining some of the more notable changes to CPT for 2019.
Some changes that may impact physicians in a variety of specialties are the revisions to the existing PICC line codes and the addition of two new combination codes to capture PICC lines placed with imaging guidance.
A PICC line is a “peripherally inserted central catheter.” These vascular lines are often inserted in patients who require chemotherapy, IV antibiotics, or supplemental nutrition. CPT states that a vascular line is a PICC line when it is inserted in a peripheral vein (e.g., basilic, cephalic, or saphenous vein) and when it terminates in a central vein (i.e., subclavian vein, brachiocephalic (innominate) veins, iliac veins, the superior or inferior vena cava, or the right atrium)..
Revised Codes
CPT 36568 and 36569 have been revised to indicate that they represent a PICC line insertion without imaging guidance.
CPT 36568 is still reported for a patient younger than 5 years old while CPT 36569 is reported for a PICC line placement in a patient 5 or older.
Codes 36568 and 36569 are reported when no imaging guidance is used to place the PICC line (meaning no guidance is used to identify and/or enter potential venous access sites and no guidance is used to confirm the final position of the PICC line).
CPT 36584 was also revised. This code is used for complete replacement of a PICC line through the same venous access. For example, if a PICC line is already in place from a right basilic access and that line is removed and replaced with a new PICC line also placed via the right basilic vein, the PICC line is replaced “through the same venous access.” CPT 36584 was revised this year to indicate that it includes replacement of a PICC line through the same venous access with imaging guidance. The imaging guidance included in this code is used both to identify potential venous access sites and to confirm the final termination point for the PICC line. If imaging guidance is used to identify the potential access site (e.g., ultrasound guidance is used to identify the basilic vein, confirm it is patent and gain access into the vein), but imaging guidance is not used to confirm the final catheter termination point (e.g., the physician placing the PICC line orders a post op chest x-ray to confirm the catheter termination point and that x-ray is read by a radiologist not by the surgeon placing the PICC line), report CPT 36584 with modifier 52.
We are reporting modifier 52 because the same physician has not completed all of the work described by the code unless he continues to use imaging guidance throughout the procedure and confirms the catheter’s final termination point with imaging guidance.
The CPT guidelines were also updated to indicate that a PICC line replacement through the same venous access without any imaging guidance, is now reported with unlisted CPT code 37799.
New Codes
CPT 36572 and 36573 are brand new codes published this year to report placement of a PICC line with imaging guidance.
Like CPT codes 36568 and 36569, these new codes are differentiated based on the age of the patient receiving the PICC line. CPT 36572 is reported for insertion of a PICC line with imaging guidance for a patient younger than 5 years old and CPT 36573 is reported for insertion of a PICC line with imaging guidance for a patient 5 or older.
The imaging guidance included in CPT codes 36572 and 36573 is imaging guidance to identify and/or enter potential venous access sites and imaging guidance to confirm the final termination point of the PICC line. As with CPT 36584, if imaging guidance is used to identify potential access sites (e.g., fluoroscopic guidance is used to identify the cephalic vein, confirm it is patent, and enter the vessel), but imaging guidance is not used to confirm the catheter’s final termination point (e.g., the physician placing the PICC line orders a post op chest x-ray to confirm the catheter’s final termination point, and that x-ray is read by a radiologist not by the physician placing the PICC line), report CPT code 36572 or 36573 with modifier 52. Again, we are reporting modifier 52 because the same physician has not completed all of the work described by the code unless he continues to use imaging guidance throughout the procedure and confirms the catheter’s final termination point with imaging guidance.
Key Guidelines:
Because CPT codes 36572, 36573, and 36584 all include imaging guidance in their descriptions, you can no longer report imaging guidance codes such as 77001 or 76937 with these codes (these codes are combination codes that include the work of placing the PICC line as well as the imaging guidance necessary to place the line). It would also not be appropriate to report imaging guidance codes such as 77001 or 76937 with 36568 or 36569 since there is now a combination code to report insertion of a PICC line with imaging guidance.
Another rule to keep in mind is that when ultrasound is used to place a PICC line, the same documentation guidelines that apply to CPT 76937 also apply to these new combination codes. Documentation for ultrasound guidance must include 1) assessing patency of the potential access site(s) with the ultrasound (and noting any obstruction of the vessel(s) where appropriate); 2) entering the vessel under real-time ultrasound visualization; and 3) permanently storing the ultrasound images.
I hope these guidelines are helpful to you as you code PICC lines in the coming year. We will continue to cover some of the key 2019 CPT updates over the next couple of weeks to keep you informed of changes that may impact your daily work.
