However, the need for more detailed (i.e., more specific) documentation is not the exclusive realm of the ICD-10 system. Although the codes differ between the two systems, the documentation issues are the same. If physicians, particularly referring physicians, provide better documentation now, better ICD-9 codes could be assigned, and they’ll be ready for ICD-10.
Physicians ordering diagnostic exams, including radiology, are notoriously vague in their documentation. As a result, many unlisted codes must be used, and denials or delayed payments may result. Getting physicians to document in detail will be a big challenge.
Procedure Performed
Indication: This 72-year-old patient with acute respiratory failure and renal failure requires hemodialysis and IV access. We have been asked to place a double lumen tunneled catheter and PICC line.
Procedure: The procedures, risks, benefits and alternatives were explained to the patient’s family, and written informed consent was obtained.
Upon beginning the procedure, the patient was hypotensive with systolic blood pressures in the 60s and hypoxic with 02 saturations in the 80s. At the time it was decided to begin with a non-tunneled right IJ catheter and then proceed as the patient’s condition permitted. Dopamine was increased during the procedure.
Patient is placed supine on the fluoroscopic table then prepped and draped in the usual sterile fashion. 1% Lidocaine was used for local anesthesia. Under ultrasound guidance, a micropuncture needle was used to access the right internal jugular vein, and a .018 wire was placed through the needle. The needle was removed then 3 and 4 French dilators were advanced over the wire. The wire and inner dilator were removed. A J-wire was placed through the outer dilator, which was then removed. A dual lumen non-tunneled 16 cm catheter was advanced over the wire and positioned with the tip at the region of the cavoatrial junction. The wire was removed, and a catheter noted to flush and withdraw easily. The catheter was flushed with heparin and sewn in place with 2-0 silk and dressed in the usual sterile fashion.
Attention was turned to the left arm, which was prepped and draped in the usual sterile fashion. 1% Lidocaine was used for local anesthesia. Under ultrasound guidance, access was obtained to a left antecubital vein with a micropuncture needle, and a 0.18 wire was placed through the needle. The needle was removed, and the dilator and peel-away sheath were advanced over the wire. The wire and inner dilator were removed. A dual lumen PICC line was advanced through the peel-away sheath with the tip remaining in the most superior aspect of the SVC. This was flushed and capped and dressed in the usual sterile fashion.
Findings: Successful placement of a non-tunneled right IJ catheter and a left antecubital dual lumen PICC as described. A non-tunneled catheter was placed, as the patient was unstable at the beginning of the procedure. Patient became more stable after placement of the non-tunneled catheter, and, therefore, the PICC line was placed at that time.
CPT Code Assignments and Documentation Tips
Assign code 36569 for the peripherally inserted central venous catheter.
36569 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; age 5 years or older
Assign code 36556 for the centrally inserted central venous catheter.
36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or alder
If the physician had provided complete documentation of the imaging guidance portion of the procedure performed above, another code could have been legitimately assigned. To allow this assignment, the documentation should have included a statement such as the following.
Ultrasound evaluation of potential access sites was performed. After successfully identifying a patent vessel, ultrasound guidance was used to puncture the vessel. A permanent recording was created for the patient record.
If this information had been present for both the central and peripheral insertions, the following code could have been assigned twice. Modifier 59 or modifier 76 would need to be added (based upon payer preference and/or requirements) to describe that the guidance was used a second time in a separate anatomical site.
76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure.)
If the documentation had been comprehensive, the following code also could have been assigned:
77001 Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure)
Although the above document does not state the use of fluoroscopic guidance, it had to be used since it is technically impossible to determine the final catheter placements without it.
As always, codes assigned depend on actual documentation not the assumed procedure. The physician should have indicated that fluoroscopic guidance was used and should have documented radiographic confirmation of the final catheter placement.
Diagnosis Code Assignments and Documentation Tips
An example of a vague statement in the above documentation can be found in the first sentence following Indication: “This 72-year-old patient with acute respiratory failure and renal failure requires hemodialysis and IV access.” Looking at this, a coder could assume that the physician meant acute respiratory failure and acute renal failure even though the physician did not indicate that the renal failure was “acute.” A coder also could read this to mean “unspecified” renal failure.
Assuming the second scenario is the case, the following codes would be assigned under the ICD-9-CM system:
586 Renal failure, unspecified
518.81 Acute respiratory failure
If “acute” was intended for the renal failure indication as well as the respiratory failure indication, then code 584.9 would be coded instead of 586. Does he have acute respiratory failure or acute renal failure?
Again assuming the second scenario, the following “unspecified” code would be assigned under the ICD-10-CM system. If “acute” was intended for the renal failure indication as well as the respiratory failure indication, then code N17.9 would be coded instead of N19.
N19 Unspecified kidney failure
J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
In this case, additional information in the documentation would have generated a more specific code. Examples of the more specific codes include the following:
N17.0 Acute kidney failure with tubular necrosis
N17.1 Acute kidney failure with acute cortical necrosis
N17.2 Acute kidney failure with medullary necrosis
N17.8 Other acute kidney failure
N17.9 Acute kidney failure, unspecified
In place of J96.00 listed above, additional documentation could lead to J96.01 (acute respiratory failure with hypoxia) or J96.02 (acute respiratory failure with hypercapnia).
