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Vascular Access Procedures by Cindy C. Parman,T CPC, CPC-H, RCC

hen a blood sample is port or catheter, this service may be be paid is when they are the sole pro- obtained and sent for reported using one of two codes: cedure performed for the patient on a W laboratory testing, the ■■ 36591: Collection of blood speci- particular service date. procedure isA essentiallyCCC the same, men from a completely implant- Hospitals billing under the Out- regardless ofMember the technique used to able venous access device. patient Prospective Payment System PROFobtain the specimen. However,IL codeE ■■ 36592: Collection of blood speci- (OPPS) will continue to report assignment and reimbursement men using established central or “packaged” services, including both vary depending on the access tech- peripheral catheter, venous, not of these specimen collection codes. nique, bundling guidelines, and/or otherwise specified. While code 36592 will never be sepa- packaging rules for the blood draw rately paid in the hospital outpatient service. The type of existing catheter dif- department, code 36591 is a “special ACCC ferentiates these specimen collection packaged” code and will be reim- ACVenipunctureTIONcodes. Code 36591 is collection from bursed when it is the only service During venipuncture, a nurse, an implanted port, and code 36592 performed for the patient that day. phlebotomist, technician, medi- is collection from a peripherally- cal assistant, or other healthcare inserted line. Guidelines published by Port Flush specialist punctures the patient’s the American Medical Association Patients who receive drug adminis- vein and obtains a blood sample (AMA) in the CPT® Manual state that tration through an implanted port for analysis. In general, a 5 ml to these codes are not separately reported may require maintenance proce- 25 ml sample of blood is adequate, when any other service is performed dures, such as ‘flushing’ of the port, depending on what blood tests have on the same date. As a result, the only between drug administration cycles. been requested. This procedure is time these port/PICC draw codes will The capture of this charge and reported with code 36415: reporting of this code may be LEGALcollection of venous blood CORNER by an area of confusion for hos- venipuncture. pitals and physician practices. Procedure code 36415 is The code for the port flush located in the surgical sec- service is 96523: irrigation tion of the CPT® Manual, of implanted venous access and documentationN should device for drug delivery sys- include the date blood was tems. drawn, the site accessed, the This code was estab- condition of the access site, lished for reporting irriga- name and discipline of the N tion required for implanted individual who obtained the venous access devices for drug CLINICALsample, and any patient com- delivery systems when these plaints or concerns (e.g., pain, services are provided on a erythema, inflammation). separate day from the injec- Note, procedure code 36415 tion or infusion services. A is not bundled or packaged notation in the CPT® Manual into drug administration on states that code 96523 is not a the same service date. charged if any other services i are provided to the patient on on/Fotol Port or PICC Access the same service date. i In some cases, a separate venous While this service will access is not required to obtain never be separately paid in the the blood sample. For patients hospital outpatient depart- Illustrat with an existing implanted port ment, code 96523 is another or peripherally inserted central “special packaged” code that catheter (PICC), these speci- will be reimbursed when it is mens can be obtained directly the sole service performed for from the vascular access device. the patient that day. For all Depending on the type of sites of service, flushing of a

10 Oncology Issues July/August 2008 vascular access port prior to or after or repeat instillation of a throm- formed with saline or a non- drug administration is considered to bolytic agent until the clot has been thrombolytic substance, however, be part of the administration service resolved. The correct code to charge code 36593 is not reported. The and not separately charged. for this declotting procedure is 36593: infusion of saline or a bolus of non- HCPCS code J1642: injection, declotting by thrombolytic agent of thrombolytic substance is included in heparin sodium, (heparin lock flush), implanted vascular access device or other services performed on the same per 10 units, may also be assigned for catheter. day and not separately charged. the heparin used to perform the port In addition to the procedure code, As you can see, a variety of port flush. Individual payer guidelines will the HCPCS Level II code for the maintenance procedures are per- determine whether there is separate thrombolytic agent should also be formed for individual patients. Can- reimbursement for the heparin; it reported. Existing codes for these cer programs must ensure that these is often considered to be a supply agents include: services are reported to payers based charge rather than a drug charge. ■■ J2997: Injection, alteplase recom- on the nature of the service ordered, binant, 1 mg performed, and documented in the Port Declot ■■ J3364: Injection, urokinase, 5000 medical record. Authoritative guide- When a patient has a port in place for IU vial lines for the charging of these services an extended period of time, the port ■■ J3365: Injection, IV, urokinase, are included in the CPT® Manual or catheter may become obstructed. 250,000 IU vial and apply to Medicare and all other Catheter obstruction is typically ■■ J2995: Injection, streptokinase, per third-party insurers. defined as the inability to infuse fluid, 250,000 IU. sluggish flow, and/or the inability to Cindy C. Parman, CPC, CPC-H, withdraw blood samples. In this situ- In general, this service must be linked RCC, is a principal at Coding ation, providers may need to declot to appropriate diagnosis codes, Strategies, Inc., Powder Springs, Ga. the implanted vascular device using a such as 996.74 (complications due thrombolytic agent (e.g., Alteplase). to vascular device) and E878.8 (sur- References This procedure necessitates the use gical operation and other surgical CPT® Manual, 2008. Available online at: of a thrombolytic agent that is intro- procedures as the cause of abnormal http://www.cms.hhs.gov/MLNMatter- duced through a syringe and then reaction of patient, or of later compli- sArticles/downloads/MM3756.pdf slowly instilled into the device or cation, without mention of misadven- http://www.cms.hhs.gov/Outpatient- catheter. This service may consist of ture at the time of operation). CodeEdit/Downloads/AttachmentBRer- eleaseFinal.pdf. Last accessed June 2, 2008. a single bolus of thrombolytic agent, If the declotting service is per-

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