​Statement on Intravascular Catheterization Procedures

Developed By: Committee on Economics
Last Amended: October 18, 2023 (original approval: October 25, 2005)

Patients undergoing anesthesia for various surgical procedures may require a more precise and sophisticated level of cardiovascular monitoring than can be obtained from standard noninvasive techniques. Placement of an arterial catheter, central venous catheter, and/or flow directed pulmonary artery catheter may be required to obtain the additional information necessary for safe, effective, and high-quality anesthesia care and life support during the perioperative period.

The need for invasive monitoring is determined by both the patient’s underlying medical condition as well as the anticipated surgical procedure. For example, although many patients undergoing abdominal surgery do not require invasive monitoring others may because of significant cardiovascular or pulmonary disease or anticipated perioperative fluid shifts. Similarly, many patients undergoing vascular surgery will require arterial catheters for precise hemodynamic monitoring but some relatively healthy patients may not. Even healthy individuals may require placement of an arterial catheter to facilitate frequent blood sampling for anticoagulation monitoring, fluctuating hormone levels, or other labs.

Use of invasive monitoring techniques:

1. Arterial Catheter (CPT code 36620) – Placement of a small catheter, usually in the radial artery, with connection to an electronic transducer allows for continuous monitoring of a patient’s blood pressure. Arterial catheters provide a reliable method for obtaining arterial blood samples facilitating proper management of blood gas, blood chemistry, and coagulation abnormalities throughout the perioperative period. Patients having intra-abdominal, cardiac, vascular, intrathoracic, spine, intracranial, or surgery for acute trauma may have rapid changes in blood pressure where arterial pressure monitoring is integral to care and continuous monitoring may be necessary for the anesthesiologist to manage these patients safely.
2. Central Venous Catheter (36555 or 36556) For pressure monitoring, volume replacement or central drug infusion – Placement of a catheter into a major intrathoracic or intraabdominal vein. This access allows the anesthesiologist to maintain a patient’s circulating blood volume through volume administration and pressure measurement. The catheter tip must reside in the subclavian, innominate or iliac veins, the inferior or superior vena cava, or right atrium to be considered a “central venous” catheter. The technique may be appropriate for patients who experience or are expected to experience significant blood or fluid loss during surgery necessitating rapid replacement. Additional indications for placement of a central venous catheter include the absence of peripheral venous access or to allow for administration of medications that are most safely and effectively administered directly into the central venous circulation.
3. Pulmonary Artery (Swan-Ganz) Catheter (93503) – Placement of a multi-lumen balloon-tipped flow-directed catheter through a major vein, the right sided cardiac chambers and into the main pulmonary artery. The catheter has the capability to monitor the central venous, pulmonary artery, and pulmonary capillary wedge pressures. It can also be used to measure the cardiac output (volume of blood being pumped by the heart per minute) as well as other important indicators of cardiovascular function. It is used for patients whose cardiac function is, or may be, compromised either prior to or during a surgical procedure. Certain pulmonary artery catheters can function as pacing devices for the heart, which may be necessary in some patients with underlying cardiac rhythm disturbances. 
4. Ultrasound Guidance (76937) – The use of ultrasound to guide placement of vascular catheters. The service includes 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.

Billing for Intravascular Catheterization Procedures: 

Although it is the position of the American Society of Anesthesiologists (ASA) that the interpretation of the data obtained from these invasive monitoring devices is accounted for in the usual anesthesia fee, the placement of invasive monitoring devices is not. As ASA has refined its Relative Value Guide® the work required for placement of invasive monitoring devices has not been included as a component of base unit values. Not all patients undergoing the same surgical procedure require the same degree of monitoring. Therefore, billing for the work of placing these devices has remained separate.

When submitting charges related to the insertion of invasive monitoring, anesthesiologists should be mindful of the following principles:

1. Charges for insertion of invasive monitors are not included in the standard anesthesia fee. These procedures are appropriately billed separately in addition to these fees. Medicare policy allows payment for placement of invasive monitoring catheters separate from, and in addition to, the usual payment for anesthesia services. Most private insurers do as well.
2. When an invasive monitor is placed before the anesthesia start time, the time required to perform the procedure should not be added to the reported anesthesia time. Placement of an invasive monitor under such circumstances is separate and distinct from the anesthesia service. If an invasive monitor is placed after anesthesia care has begun, both services may be provided concurrently. For concurrent services it is not necessary to deduct the procedure time from the reported anesthesia time.^a,b,c
3. When placing a pulmonary artery catheter (93503), access to the central venous circulation is included. Code 36556 should not be used unless there is a specific indication or need for a separate and distinct central venous catheter introduced via a separate skin insertion site (see No. 4 below).
4. Occasionally a central venous catheter (36556) may be placed at the time of surgery. Postoperatively, indications for placement of a pulmonary artery catheter (93503) may develop in the intensive care unit. When these two procedures are performed at different times and as a result of a change in the patient’s condition it is appropriate to bill for both.
5. In some circumstances two separate access sites to the central venous circulation are required. For example, one site may be used for the measurement of cardiovascular function the other dedicated to the administration of medications or fluids. This could result in multiple charges: either two for 36556, or one for 36556 and one for 93503. 
6. A central venous catheter may be placed at the time of surgery at the request of the surgeon or another physician to facilitate postoperative management of the patient. For example, for the administration of total parenteral nutrition, administration of medications such as antibiotics or chemotherapeutic agents, or for hemodialysis. Such central venous catheter placement is unrelated to the anesthetic and is separately billable. 
7. Arterial catheters (36620) allow monitoring of the systemic arterial pressure, not the central venous circulation. Arterial catheter placement should never be bundled with procedures for monitoring the central circulation (36555, 36556, or 93503). 
8. Ultrasound-guided vascular access (76937-26) to facilitate placement of arterial and central venous catheters is not bundled with arterial catheter placement (36620), central venous catheter placement (36555, 36556), or pulmonary artery catheter placement (93503). Ultrasound guidance should be billed as an addition service when used for placement of such intravascular catheters. 

References:

a) CPT Assistant Feb 97:4
b) CPT Assistant May 07:9
c) Medicare Claims Manual Chapter 12, 50(F)