Peripherally inserted central catheters

Learn the codes for central venous access procedures.

Peripherally inserted central catheters (PICCs) are commonly used for central venous access due to ease of insertion and lower procedural risks such as hemo- or pneumothorax. With a central venous access catheter, the catheter tip terminates in the subclavian, brachiocephalic (innominate), or iliac vein. The basilic, cephalic, and saphenous veins are typical PICC entry sites. PICC devices can also be attached to a subcutaneous port and then are sometimes referred to as “PICC ports.”

Image by Getty Images
Image by Getty Images

PICCs are usually placed to provide temporary access for infusions expected to last about two weeks to three months, often IV antibiotics. PICCs are associated with a higher rate of catheter-related deep venous thrombosis than centrally inserted central catheters. Because of this predisposition to thrombosis, PICCs are relatively contraindicated for patients with chronic kidney disease who may require future hemodialysis access. PICCs do not increase or reduce the risk of catheter-associated bloodstream infection compared with centrally inserted central catheters.

PICC placement or replacement may be performed with or without imaging (ultrasonic) guidance. Once the vein is accessed, a catheter is placed over a guidewire and positioned in the central veins. Catheter position is confirmed by X-ray, fluoroscopy, or ultrasound.

Code 36569 is used for placement of a PICC, without a subcutaneous port or pump, without imaging guidance for patients ages 5 years or older. When imaging guidance is utilized for placing a PICC without a subcutaneous port or pump (in patients ages 5 years or older), use code 36573. For a PICC with a subcutaneous port or pump, use code 36571. (See Table for a list of PICC placement codes.)

For complete replacement of a PICC, without a port or pump, with imaging, use code 36584; without imaging, use code 37799 (unlisted vascular surgery procedure). For complete replacement of a PICC with a port or pump, use code 36585.

These are bundled service codes that include all imaging necessary to complete the procedure, image documentation, associated radiological supervision and interpretation, venography (if performed), and imaging to document the final central position of the catheter tip. Do not separately report chest X-ray codes 71045-71048 for documentation of the final position of the catheter tip.

Documentation of ultrasonic guidance should include evaluation of the potential entry sites, patency of the entry vein, and real-time ultrasonic visualization of needle entry into the vein. Representative images must be stored in the patient's permanent medical record.

“Imaging guidance” does not include magnetic guidance, which has no images. In the rare circumstance where imaging guidance is utilized without confirmation of catheter tip placement, append modifier 52 (reduced services) to the PICC code.

A “midline” catheter (sometimes described as “short PICC”) terminates in a peripheral vein about three to eight inches from the insertion site and therefore is not a central venous access device. Infection rates associated with midlines are low, but thrombosis is more common than with a PICC. Midline catheter placement in patients ages 3 years and older is reported with code 36410 (venipuncture requiring the skill of a physician or other qualified health care professional). Based on CPT-4, code 76937 (ultrasonic guidance) may be separately assigned with code 36410 when ultrasonic guidance is utilized. The 76937 code requires the same documentation of ultrasound guidance noted above.

In summary, coding of PICC placement is complex and involves consideration of the location of the catheter tip, whether imaging guidance was utilized, whether the PICC was connected to a subcutaneous port or pump, and whether this was initial placement or replacement. Documentation required for ultrasonic guidance includes evaluation of the potential entry sites, patency of the entry vein, and real-time ultrasonic visualization of needle entry into the vein. Representative images must be stored in the patient's permanent medical record.

Ask Dr. Pinson

Q: My question is about a patient hospitalized for a surgical procedure, discharged after a few days, and then rehospitalized due to a complication of the surgery (for example, contrast-associated acute kidney injury). If the condition is not included in the readmission reduction measures, would the subsequent admission fall under the original diagnosis-related group (DRG) or a separate new one? Is there a time period following the initial discharge when a readmission has to be included with the first admission in a single claim?

A: Yes, the timing matters in the coding of any readmission. The answer is found in the Medicare Claims Processing Manual, Chapter 3, Section 40.2.5 (Repeat Admissions). “When a patient is discharged/transferred from an acute care Prospective Payment System (PPS) hospital, and is readmitted to the same acute care PPS hospital on the same [calendar] day for symptoms related to, or for evaluation and management of, the prior stay's medical condition, hospitals shall adjust the original claim generated by the original stay by combining the original and subsequent stay onto a single claim ...” The same calendar day means not 24 hours, but midnight to 11:59 p.m. on same day. So it would be a separate claim if the readmission is for another condition or if the patient is readmitted for the same condition the next or a subsequent day. If the original admission was for one of the four medical conditions or two surgical conditions targeted by the readmission reduction measures, it also counts against the hospital's performance ranking as an unnecessary readmission.

Q: Can the Glasgow Coma Scale score be coded from clinicians' descriptions of patient responses to stimuli, such as eye opening, motor, and verbal? For example, if the clinician documented, “Pt motor response is none. Will open eyes to painful stimuli. Pt is lethargic and unable to follow commands,” is that sufficient to assign a score?

A: Thank you so much for this interesting question. Coding Clinic, Second Quarter, 2015, page 17, answers the question for us: “These codes are used only when the individual score(s) or numeric values are documented within the health record.” A clinician's description of a patient's neurological findings cannot be translated into a numerical score.

Q: In your CDI Pocket Guide and elsewhere, you have stated that “Before a Glasgow Coma Scale (GCS) code can be assigned, an associated diagnosis must be documented by the provider, such as cerebrovascular accident, brain edema/compression, hemorrhage, overdose, anoxia, brain trauma, or symptoms like altered mental status, stupor, comatose.” I was taught to code the GCS only when coma, unresponsive, stupor, obtundation, or similar terminology was used in the diagnosis. Can you help me understand the official coding guidance for this?

A: As you know, only the GCS component scores are coded and not the total score. Also, the 2020 ICD-10-CM Official Guidelines for Coding and Reporting (OCG) Section I.B.14 requires that an associated condition making the GCS pertinent to the encounter must be documented. Nothing in OCG or Coding Clinic indicates that any specific condition is required, only that there be a pertinent one. In fact, there are two Coding Clinics that make specific reference to stroke and brain trauma as pertinent diagnoses for coding the GCS scores.

Q: How should we handle documentation of “hypercapnic encephalopathy”? Can it be considered a metabolic encephalopathy for which the clinician should be queried?

A: Hypercapnic encephalopathy is caused by impaired ventilation of the lungs typically associated with severe chronic lung disease. It refers to an altered level of consciousness due to carbon dioxide accumulation resulting from hypercapnic respiratory failure that depresses sensorium. It may certainly be considered a metabolic encephalopathy.

For a diagnosis of “hypercapnic encephalopathy,” the ICD-10-CM code is G93.49 (other encephalopathy), counted as a comorbidity/complication (CC) for the DRG, whereas “metabolic encephalopathy” is code G93.41, a major CC (MCC) that would increase the weight of the final DRG. Therefore, a query would certainly be recommended.

Since the altered level of consciousness associated with hypercapnic encephalopathy may range from lethargy to deep coma, the Glasgow Coma Scale should be recorded at least once and reviewed for possible component scores that would lead to assignment of an MCC or a diagnosis of coma.