Hit the Mark & Land Like a Champion: Central Venous Insertion

Central Venous Insertion

Hit the Mark & Land Like a Champion: Central Venous Insertion

Hit the Mark & Land Like a Champion: Central Venous Insertion

By Marcy Garuccio, ACS-AN, CANPC, CPMA, CPC, SME, Fellow; Director of Coding and Documentation Education

Reviewing documentation of central venous catheters placement can be a challenge for coders and auditors.

Coders often see the indication noted on the paper anesthesia record, “insertion of CVP”, and are instructed to code the appropriate code. Practitioners might not realize, and unfortunately find out in post audit findings that the  documentation requirements listed by the AMA CPT guidelines may not be documented sufficiently and are missing necessary elements that would support the service.

AMA CPT guidelines state “to qualify as a central venous access catheter or device the tip of the catheter/device must terminate in the subclavian, brachiocephalic (innominate) or iliac veins, the superior or inferior vena cava, or the right atrium. The venous access device may be either centrally inserted (jugular, subclavian, femoral vein, or inferior vena cava catheter entry site) or peripherally inserted (e.g., basilic, cephalic, or saphenous vein entry site). The device may be accessed for use either via exposed catheter (external to the skin), via a subcutaneous port or via a subcutaneous pump.”  The guidelines go on to detail the five categories and the requirements: insertion, repair, partial replacement, complete replacement, and removal.

Therefore, hitting the mark with complete documentation of all the requirements including “tip termination site” is necessary.

These key elements are commonly reviewed in audits:

  • Type of line placed
  • Informed consent obtained
  • Sterile technique deployed
  • Needle size
  • Entry sites and structure
  • Tip termination site
  • Place by
  • Placement start and time
  • Ultrasound usage with hard copy image storage and dynamic use notation

Documentation Tips:

For paper charting, it would be recommended that the checklist be incorporated into the anesthesia record or be an additional document that would accompany the anesthesia documentation to the coders.

For practices utilizing EMR systems, the proper template development will prompt and assist the providers to capture all the necessary elements needed to document performance.