PICC vs Midline Catheters

By Leslie Bargfrede, CPC, CIRCC, RCC, Corporate Coding Manager – Interventional Radiology with Zotec Partners

In recent years there has been evolving clinical evidence which has drawn attention to catheter related blood stream infections (CRBSI) associated with central venous access devices (CVAD), specifically, peripherally inserted central catheters (PICC). As such, the use, efficacy and prevalence of midline catheters is advancing. With the popularity of midline catheter placement increasing, the following information is essential, not only for documentation and medical record accuracy, but also for appropriate code assignment and reimbursement. For 2019, CPT has made some changes to this code category and provided further clarifying instructions for use.

CPT Definitions

Peripherally inserted central catheters (PICC)

Documentation must state the catheter tip position terminating in one of the central veins:

  • Subclavian vein
  • Brachiocephalic (innominate) vein
  • Iliac veins
  • Superior Vena Cava
  • Inferior Vena Cava
  • Right atrium

Midline catheters

Best practice is to document the catheter tip position terminating in one of the peripheral veins:

  • Axillary vein
  • Basilic vein
  • Cephalic vein
  • Brachial vein

* New for 2019

Two new codes have been added for PICC line procedures to include all imaging guidance, documentation, and supervision and interpretation required to perform the procedure.

*36572 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation required to perform the insertion; younger than 5 years of age

  • (For placement of peripherally inserted non-tunneled central venous catheter, without subcutaneous port or pump, without imaging guidance, younger than 5 years of age, use 36568)

*36573 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation required to perform the insertion; age 5 years or older

(For placement of peripherally inserted non-tunneled central venous catheter, without subcutaneous port or pump, without imaging guidance, younger than 5 years of age, use 36569)

(Do not report 36572, 36573 in conjunction with 76937, 77001)

Existing codes that have been revised (**) for use when imaging guidance is not utilized.

**36568 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, without imaging guidance; younger than 5 years of age

  • (For placement of peripherally inserted non-tunneled central venous catheter, without subcutaneous port or pump, with imaging guidance, younger than 5 years of age, use 36572)

**36569 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous

port or pump, without imaging guidance; age 5 years or older

  • (Do not report 36568, 36569 in conjunction with 76937, 77001)
  • (For placement of peripherally inserted non-tunneled central venous catheter, without subcutaneous port or pump, with imaging guidance, age 5 years or older, use 36573)

The PICC line replacement code has also been revised to include all imaging guidance, documentation, and Supervision & Interpretation required to perform the procedure.

**36584 Replacement, complete, of a peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, through same venous access, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation required to perform the replacement

  • (For replacement of a peripherally inserted central venous catheter (PICC) without subcutaneous port or pump, through same vascular access, without imaging guidance, use 37799)
  • (Do not report 36584 in conjunction with 76937, 77001)

CPT Guidelines

  • Codes 36572, 36573 and 36584 include all imaging necessary to complete the procedure, image documentation (representative images from all modalities used are stored to patient’s permanent record), associated RS&I, venography performed through the same venous puncture, and documentation of final catheter position.
  • Ultrasound guidance for PICC placement should include documentation of evaluation of the potential puncture sites, patency of the entry vein and real-time ultrasound visualization of needle entry into the vein.
  • Chest x-ray codes 71045, 71046, 71047, 71048 should not be reported for the purpose of documenting the final catheter position on the same day of service as PICC line placement or replacement.
  • Report 36572, 36573, 36584 with modifier 52 when performed without confirmation of catheter tip location.
  • PICCs placed using magnetic guidance or any other guidance modality that does not include imaging or image documentation are reported with 36568, 36569. [eg., Sherlock 3CG]
  • Midline catheters, by definition, terminate in the peripheral venous system. They are not central venous access devices and may not be reported as a PICC service.
  • Midline catheter placement may be reported with 36400, 36405, 36406, or 36410.

Documentation

  • Type of device placement, replacement or exchange must be defined as PICC or midline catheter
  • Device placement, replacement or exchange must document final catheter tip position
  • Type of imaging guidance used (fluoro and/or ultrasound) must be documented
  • The use of ultrasound guidance must include performance and documentation of all elements above to support billing.

Note: CPT codes and definitions for centrally placed, replaced, removal, and repair catheter codes have not changed for 2019.

Description 2018 Coding 2019 Coding
PICC with US and fluoro guidance, 5+ yrs 36569, 76937, 77001 36573
PICC with US and fluoro guidance, < 5 yrs 36568, 76937, 77001 36572
PICC without any imaging guidance, 5+ yrs 36569 36569
PICC without any imaging guidance, < 5 yrs 36568 36568
PICC replacement with fluoro guidance 36584, 77001 36584
PICC replacement without imaging guidance 36584 37799
Midline placement with US guidance 36410, 76937 36410, 76937
Midline placement with fluoro guidance 36410, 76000 * 36410, 76000 ***


*** Note: Fluoro guidance code 77001 cannot be assigned for midline placement as this code is defined for use with central venous devices, per CPT definition. Therefore, when fluoro guidance is used to place a midline catheter, code 76000 must be used.