Central Venous Access PICC Line Placements Including All Imaging Guidance

Central venous access and PICC line placements were a bit of a headache for coding this year due to new codes, language and guidelines that went into effect in January.

For patients requiring longer term access than provided by a regular IV, or when smaller veins typically used for an IV can’t be accessed, central venous access catheters may be placed. These access catheters may be inserted in a central site (i.e., jugular, subclavian, femoral vein or inferior vena cava) or peripherally (i.e., basilic, cephalic or saphenous vein). Peripherally inserted central catheters are commonly referred to as PICC lines.

Regardless of where the catheter is inserted from, to qualify as a central venous access the tip of the catheter must end up in one of the following locations:

1. Subclavian vein
2. Brachiocephalic (innominate) vein
3. Superior vena cava (SVC)
4. Inferior vena cava (IVC)
5. Right atrium (right heart)
6. Iliac vein

What if the catheter does not end in one of those locations?

If the catheter ends anywhere outside one of the six sites listed above, it is not a central venous catheter. Instead, it is considered a midline catheter. In prior years, even if the catheter ended up outside of one of those locations, if the intent was a PICC line placement coding as such with a 52 modifier was appropriate. In 2019, when the new PICC line placement codes (36572, 36573) were introduced, CPT^® also issued a clarification regarding what determines a central venous catheter vs. a midline catheter:

“Midline catheters by definition terminate in the peripheral venous system. They are not central venous access devices and may not be reported as a PICC service. Midline catheter placement may be reported with 36400, 36405, 36406 or 36410.”

This change negates instructions previously used for years. For IR departments this means that it is critical to know where the catheter ended up in order to code the service properly – code based on what was done vs. intent.

Including ALL imaging guidance

In addition to the central vs. midline clarification released last year, CPT also introduced the two new codes referenced above for PICC line placement. These codes now include “all imaging guidance, image documentation and all associated radiological supervision and interpretation required to perform the insertion.”

This definition clearly bundles any imaging guidance used for the initial venous access, but one of the primary questions asked throughout the year has been what about chest x-rays performed as part of the catheter placement? These chest x-rays are generally done to confirm placement and were in the past separately reported. However, when we look closely at the code descriptions, they state including all imaging guidance. All imaging guidance in this case includes the chest x-rays for final confirmation of placement and “71045, 71046, 71047, 71048 should not be reported for the purpose of documenting the final catheter position on the same date of service” as placement.