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Procedure
Practice 04/15/99 - Coding
Recommendations
Feature
Article 04/15/99
Venous
Access Devices
Types
of Devices - Complications
- Coding Tips
Over 5 million central venous catheters and
over 200 million peripheral intravenous catheters are placed
annually in the United States. Catheter clotting and other
complications cost the healthcare system over $1 billion each
year. This month, we review the types of devices used, how
they are placed, and related complications and provide some
coding tips.
Central Venous Access
Central venous access systems are routinely
used in the medical management of many types of patients.
These devices provide vascular access for the delivery of
fluids, medications, blood products, chemotherapy, and parenteral
nutrition solutions. They are also useful for patients who
require hemodialysis, frequent blood sampling, or hemodynamic
monitoring. To be considered a central line, the internal
catheter tip must be located in the vena cava, subclavian,
brachiocephalic, innominate, or iliac veins. Central venous
catheters, partially implanted venous access devices, peripherally
inserted central catheters, and implanted ports are types
of central venous access systems.
Central venous catheters
(CVCs) are inserted
into deep veins such as the subclavian, jugular, or femoral
veins, and then advanced into the vena cava. The catheter
must be placed in a large thoracic cavity vessel for several
reasons: 1) the large volume of blood around the end of the
catheter dilutes chemotherapeutic drugs and minimizes venous
damage; 2) thoracic lines provide optimal central venous pressure
monitoring because no valves are located between the end of
the catheter and the heart; and 3) during hemodialysis, the
larger central catheter provides optimal blood return through
the dialysis coil into the vein. Venous access is via the
external end of the catheter. Groshong, Leonard, Quinton,
Cook, Shiley, and dual and triple lumen are examples of central
venous catheters.
CVCs may be placed percutaneously or via cutdown
technique. In the percutaneous procedure, the skin is prepped
and draped and local anesthesia applied. A needle with a syringe
attached is placed into the vein. Venous access is confirmed
by drawing blood into the syringe. Next, a guidewire is passed
through the needle, the needle is removed, and a dilator and
sheath are threaded over the wire. The dilator is removed
and the catheter positioned. The sheath is removed and the
catheter end is brought out through the skin and sutured into
place on the anterior chest. A post-procedure chest x-ray
or fluoroscopy is usually done to confirm correct catheter
placement. The catheter should not be located in the atrium
or ventricle of the heart because it may erode through the
heart muscle. In addition, the catheter tip should not be
so close to the skin that it may dislodge from the vein.
Placement with the cutdown technique is often
used on children or other patients who have veins that are
difficult to access percutaneously. Patients who had had frequent
percutaneous sticks for venous access may have scarred veins
that can no longer be used. In this procedure, the skin is
prepped and draped, and an incision is made to expose a vein.
Under direct vision, the vein is isolated. The surgeon makes
a small "nick" in the vein with a scalpel to open
it, and the catheter is inserted through this opening. The
catheter is advanced so that the tip is in proper position,
and placement is confirmed with chest x-ray or fluoroscopy.
Partially implanted
venous access devices (tunneled devices)
have a visible external site that is remote from the venous
entry site. Their placement requires a different surgical
technique from that of central venous catheters. During placement
of these devices, the surgeon must first make an extensive
subcutaneous tunnel from the external site to the point of
venous entry. Only after the tunnel is developed can the catheter
be threaded beneath the skin to the point of venous access.
Partially implanted devices do not have subcutaneous reservoirs.
Examples of this type of device are Broviac and Hickman catheters.
Peripherally inserted
central catheters (PICCs) may
remain in situ for up to six months. The catheter is placed
into one of the large antecubital veins of the anterior forearm
and then threaded into the superior vena cava above the right
atrium. As with other central line placements, fluoroscopy
or x-ray is routinely done to confirm correct placement.
Implanted ports or
reservoirs are special types
of central venous access systems that are completely implanted
under the skin. These ports are often referred to as TIVADs
(totally implantable venous access devices). Implantable VADs
consist of a reservoir, an inlet septum in the center of the
reservoir, and an outlet catheter that is placed into a vein.
The inlet septum is soft and pliable and designed to accept
multiple punctures from special types of noncoring needles
(e.g., Huber needles) while maintaining its leak-tight integrity.
The needle is used to infuse medication into the reservoir.
The catheter is anchored to muscle or subcutaneous tissue
with sutures, and no part of the TIVAD system protrudes through
the skin. TIVADs provide reliable vascular access for patients
who require long-term drug or fluid therapy. They may be left
in place for months at a time. Implanted ports are usually
made of titanium or plastic. Patients are generally more comfortable
and suffer fewer complications with TIVADs versus nonimplantable
central lines. Physical activity is not limited, quality of
life is improved, and maintenance of the system is relatively
easy. Product names include BardPort, NorPort, Medtronic,
MicroPort, Button Port, Q-Port, Hemo-Cath, Perm-a-Cath, Port-a-Cath,
LifePort, and Infuse-A-Port.
To insert a TIVAD, the surgeon creates a subcutaneous
pocket to hold the port. The VAD is usually placed under the
pectoral muscles or skin in the anterior chest below the clavicle.
The catheter is then inserted into the desired vessel. The
port and catheter are connected and the skin is then closed.
The procedure is generally done under local anesthesia.
Implantable Intravenous
Infusion Pumps
An infusion pump is a device that provides
continuous medication for chronic pain management. It may
also be used to administer chemotherapeutic agents such as
5-fluorouracil. Infusion pumps allow patients to receive some
of their treatment at home. When the infusion pump reservoir
is empty, the patient returns to the outpatient clinic for
a medication refill. Examples of infusion pumps are CADDs,
INFUSAIDs, and Synchromeds.
One type of implantable infusion pump is a
disk-shaped device with two chambers, a side port, and a catheter.
One chamber contains the medication to be infused. The other
chamber contains a fluorocarbon fluid that expands at body
temperature and exerts pressure on the pump, thereby forcing
the medication to be infused into the catheter. The side port
is used for bolus injections and catheter flushing. Pump refills
and bolus injections are done percutaneously with a Huber
needle to access the self-sealing ports of entry.
Another type of implantable pump is powered
by a lithium battery. It consists of a refillable reservoir,
an electronic control module, and a miniature pump. A self-sealing
septum permits refill or evacuation of the reservoir with
a Huber needle. This type of pump is programmable with a device
external to the body, thereby allowing for adjustments in
flow rate after the device is implanted.
To insert an implantable pump the surgeon
creates a subcutaneous pocket under the skin. The pump is
inserted into the pocket and the attached catheter is then
positioned at the desired site. Infusion pumps may be part
of a central venous access device if the catheter tip is placed
in one of the venous sites listed above. However, infusion
pumps may also be placed in the flank area with catheters
placed into the epidural space.
Peripheral Intravenous
Devices
Peripheral venous catheters are inserted into
superficial peripheral veins, usually in the upper extremities.
They differ from PICCs in that they are not advanced into
the vena cava. Topical anesthesia may be used at the time
of insertion. The skin is punctured with a needle and the
catheter system is held in place with tape. Like CVCs, peripheral
catheters are used for direct venous access, but for shorter
periods of time. The peripheral system is composed of a short
catheter attached to either intravenous tubing or to a plug
with an inlet septum (a heparin lock or hep-lock). Examples
of peripheral catheters are Jelco catheters, Abbott catheters,
and Angiocaths. When used intermittently, the hep-lock allows
the catheter to be capped while remaining in place for future
venous access if needed.
Catheter Occlusion
The most common complication associated with
venous access devices, catheter occlusion can result in loss
of function, delays in treatment, high costs, and patient
discomfort. Additionally, intraluminal clotted blood and fibrin
increase the risk of catheter related sepsis. If not treated,
it can lead to complete occlusion of the vessel (venous thrombosis).
The incidence of catheter occlusion is reported in the range
of 50% to over 90%.
Catheter occlusion may result from either
external or internal mechanical obstruction. Kinks or restrictions
in the external IV tubing or in the catheter itself can reduce
or totally obstruct flow through the lumen. Other causes of
catheter occlusion include blood clots, fibrin build-up, and
drug precipitate. A fibrin sheath normally forms along the
outside of the catheter soon after insertion and can extend
from the insertion site to the catheter tip. The sheath may
encase the catheter and limit its functionality. Occlusion
may also occur following aspiration of blood into the catheter.
The catheter is routinely flushed with normal saline to remove
any blood residue. However, if this procedure is not followed
appropriately, blood may clot within the catheter lumen. Another
potential source of intraluminal clotting is associated with
the use of add-on connectors. These commonly used connectors
attach to the catheter hub and are accessed during infusion
and aspiration procedures, either through direct needle-free
connection or with a blunt cannula. Many of these devices
cause a reflux of blood into the tip of the catheter during
disconnection. Depending on the time between infusions, an
intraluminal clot can easily develop before the next infusion.
Coagulation and clot formation can also result from an infusion
bag that has run dry. Clot occlusion also occurs due to retrograde
flow of blood into the catheter tip during fluctuations in
central venous pressure, for example, when a patient coughs
or sneezes.
Resolution of catheter occlusion is a costly
procedure. A fibrinolytic agent such as streptokinase or urokinase
is used to lyse the fibrin sheath and cleanse the catheter
of clotted blood. This procedure can take from 5 minutes to
24 hours, and the cost can be extensive. The most significant
impact is the delay of the patient’s infusion therapy.
Successful antibiotic regimens require consistent drug levels
in the blood stream. When delays in dosing occur, treatment
efficacy can be impacted significantly, ultimately leading
to higher costs. If the catheter is being used for pain management,
significant patient discomfort can occur.
Air Embolus
A more critical complication associated with
central venous catheters is air embolus. If the system is
opened to air for an extended period of time, the patient
is at risk of developing an air embolus, which can be fatal.
Although occurrence is rare, avoidance of this complication
is paramount. Most central venous catheters have a clamp attached
to the external segment of the catheter for the patient or
practitioner to apply during routine disconnects, thereby
avoiding this risk.
Infection
Infection is a well-recognized complication
of all types of catheters. Infections are potentially life-threatening,
particularly in patients with neutropenia. Patients with the
acquired immune deficiency syndrome (AIDS) are more likely
to experience catheter-related infections than other patients.
Local infections, including exit site and port pocket, and
tunnel infections can occur as well as systemic infections
from colonized thrombi or fibrin sleeves or from intraluminal
or extraluminal catheter colonization. Partly due to the increased
use of central venous catheters over the past 10 years, the
organisms identified in neutropenic and immuno-compromised
patients with bacteremia have changed over this period. Formerly,
gram-negative aerobes from the gastrointestinal tract (i.e.,
E. coli, Klebsiella, Pseudomonas aeruginosa) caused most infections.
Today they cause 25% to 33% of infections, while gram-positive
aerobes from the skin (i.e., Staph aureus, Staph epidermis,
and streptococcus species) are responsible for over 50% of
all infections. Candida species are isolated 5% to 7% of the
time. When a patient has signs of systemic infection, cultures
of all possible sites of infection (blood, wound, urine, sputum,
catheter exit site, etc.) are drawn before beginning antibiotic
therapy. Catheter-related infections may be treated by line
removal, antibiotic administration through the involved catheter,
or by line removal and systemic antibiotic administration.
Extravasation
The leakage of infusate from a vein into the
subcutaneous space is called extravasation and is a relatively
infrequent complication of central venous catheters. It occurs
through several mechanisms, but causes similar symptoms in
the area of leakage. The most common symptom is the onset
of pain, burning, or stinging in the chest, in the clavicular
area, port pocket, or along the subcutaneous tunnel during
or after infusion.
Extravasation most often results from needle
dislodgement, solution backtracking, and occasionally from
catheter damage, separation or malposition of the catheter
tip. When extravasation is suspected, infusion is stopped
immediately.
Backtracking occurs when a partially occlusive
thrombus forms at the catheter tip, forcing infusate to flow
back and out of the vein. It occurs most often in catheters
inserted percutaneously. Catheter damage is rare but can occur
during a difficult surgical placement or from a poor connection
between a port and catheter. Catheter tip malposition results
from erroneous insertion of the catheter into a small tributary
of the superior vena cava, from migration of a correctly placed
catheter, or from perforation of the superior vena cava or
endocardium by the catheter tip.
"Pinch-off" syndrome can damage
catheter tubing and result in extravasation. This syndrome
occurs when a subclavian catheter is repeatedly compressed
between the clavicle and first rib. The angle between these
two bones is narrow in some people and friction from body
weight with sitting and shoulder movement may cause flattening
of the catheter.
- Use ICD-9 procedure code 38.93 for percutaneous
insertion of a central venous catheter or PICC line unless
the line is for central pressure monitoring or hemodialysis.
Central lines for pressure monitoring are coded 89.62.
Use 38.95 for hemodialysis catheter insertion.
CPT code selection is based upon the age of the patient.
Use either 36488 or 36489
as appropriate.
- Cutdown insertion of a central venous catheter is assigned
ICD-9 code 38.94. Again, the correct CPT
code depends upon the patient’s age; choose either
36490 or 36491.
- Do not assign ICD-9 or CPT procedure codes for simple
peripheral IV insertion.
- TIVAD insertion is coded 86.07. If an
infusion pump is also implanted, assign 86.06
in addition to 86.07. Assign CPT code 36533
for all TIVAD insertions as well as for partially implantable
or tunneled venous access device insertions. Use 36530
for the pump implantation.
- If medication infusion is begun at the time of central
venous catheter insertion, remember to assign an ICD-9-CM
code from the 99.20-99.29 series for the
therapeutic substance administered.
Practice Makes Perfect!
Are you ready for some hands-on practice?
Read the patient report(s) on our procedure
practice page. Assign the appropriate codes and
then compare your answers with our coding
recommendations. Good luck!
Back to:
Top
- Types of Devices -
Complications
- Coding Tips
If you have comments or suggestions about our code selections
or about any topic on our Coding Edge® pages, please e-mail
us at codingedge@lagunamedsys.com.
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