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CODING & BILLING: Tunneling inherent in placement of CVA device

Medical Device Reimbursement and Compliance Alert, July 18, 2005

Q: When a physician places a central venous access (CVA) device with a subcutaneous port, is it appropriate to assign 36560-36561-even if the physician did not document that the catheter was tunneled during the procedure? From the research I have done it appears that the tunneling is inherent in the procedure. Therefore, even if it was not specifically documented, you could still assign the port placement CPT codes.

A: Tunneling is inherent in and integral to the procedure represented by CPT codes 36560-36561. Physicians must document that this tunneling is in fact performed during the insertion procedure to appropriately report this series of codes. In the absence of this crucial piece of physician documentation stating that the CVA device was "tunneled," the procedure would generally be coded with CPT series 36570-36571. These codes include the definition "peripherally inserted [CVA] device, with subcutaneous port" and do not include "tunneling."

Reporting 36560-36561 without the appropriate documentation can be perceived as fraudulent, especially if done knowingly in the absence of appropriate documentation. Train your coders to carefully examine the operative reports for this key documentation, educate your physicians on the appropriateness of accurate and complete documentation, and instruct your coders to code this scenario conservatively.

Source: July 2005 APC Coding Letter