Vascular Access FAQ

Vascular access procedures are frequently performed to ensure timely and appropriate administration of medications, fluids, and blood products. The most common types of vascular access procedures utilized in the emergency department include peripheral intravenous (IV) access, central venous access, and intraosseous access.

Peripheral IV access is the most commonly used method for vascular access in the emergency department. It involves inserting a catheter into a peripheral vein, typically in the arm or hand. This allows for the administration of medications, fluids, and blood products. Peripheral IV access is relatively quick to perform, making it the preferred choice for most emergency department procedures.

Nursing or other ancillary staff perform most PIV procedures in the emergency department. They are not reportable as a physician/QHP service unless there is a medical reason for the ED physician/QHP to take over the procedure. The CPT codes for routine PIV access are:

• 36415: Collection of venous blood by venipuncture is used when blood is drawn to collect a blood sample for laboratory testing.
• 36000: Introduction of needle or intracatheter, vein, covers the insertion of the needle or intracatheter into the vein for subsequent catheter placement.

If the clinical circumstances dictate that the ED physician/QHP performs the PIV procedure to administer fluids, medications, or blood products, one of the following CPT codes would be used to report the placement of the catheter into the vein:

• 36400 - Venipuncture of femoral or jugular vein, younger than age 3 years, necessitating the skill of a physician/QHP, not to be used for routine venipuncture.
• 36405 - Venipuncture of scalp vein, younger than age 3 years, necessitating the skill of a physician/QHP, not to be used for routine venipuncture.
• 36406 - Venipuncture other veins, younger than age 3 years, necessitating the skill of a physician/QHP, not to be used for routine venipuncture.
• 36410 - Venipuncture any vein, age 3 years or older, necessitating the skill of a physician/QHP (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture).

Additional CPT codes would be applicable for vascular access achieved through cutdown. However, cutdown procedures by ED physicians/QHPs have become exceedingly rare due to the advances in vascular access (e.g, intraosseous access) in emergency departments.

As the CPT codes are age and vein-specific, the documentation should include the patient's age and the specific vein accessed. Venipuncture CPT codes are not intended for standard blood draws and should only be utilized when the procedure requires the expertise of a physician/QHP. Therefore, the documentation should detail the clinical justification for involving a physician/QHP.

As with any procedure performed in the emergency department, a procedure note is necessary.  The procedure note should contain, when relevant, the reason for the procedure, specifics such as the site, method, and instrument size, evidence of completion if necessary, and any complications encountered. If ultrasound guidance was employed, notate as much with “under real-time ultrasound guidance” type statements and confirm that images have been saved.

Placing a central venous catheter (CVC) involves the insertion of a catheter into a large central vein, such as the subclavian, brachiocephalic (innominate), internal jugular, or femoral vein. This method is often used when peripheral IV access is difficult or impossible to obtain or for specific indications such as administration of vasoactive medications, parenteral nutrition, or hemodialysis.

Central venous access requires more skill and expertise than routine peripheral IV access and is typically performed by the ED physician/QHP. For CVC procedures, the following CPT codes are reported for inserting a catheter into the vessel and placing the catheter tip within the central venous system:

• 36555 - Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age
• 36556 - Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older.

Whenever a procedure is performed in the emergency department, the physician/QHP should create a procedure note. The note should include the reason behind the procedure, details such as the site, method, and instrument size and information about any complications encountered. If ultrasound guidance was used, it should also be mentioned in the note, with statements such as "under real-time ultrasound guidance," and it should be confirmed that the images have been saved.

According to CPT and reiterated in the September 2023 issue of CPT Assistant, two essential criteria exist for appropriate central venous catheter placement coding - 

• The catheter should be inserted through a central vein. In the emergency department, this typically involves the internal jugular, subclavian, brachiocephalic (innominate), or femoral veins.
• The distal tip of the catheter must terminate in the subclavian, brachiocephalic (innominate), or iliac veins; the superior or inferior vena cava; or the right atrium.

Following the insertion of a central line, it may be common for the ED physician/QHP to obtain an imaging study to evaluate for pneumothorax or other complications or to verify the accurate positioning of the catheter. While some specialties may routinely store images of the catheter tip placed under fluoroscopy, it is not commonly utilized in the emergency department. It is unreasonable to subject patients to the risks associated with radiation exposure for an imaging study only to confirm the placement of a CVC, except in cases where there is suspicion of incorrect placement or catheter-related complications.

The typical ED procedure for inserting a CVC ensures that the catheter's tip will be appropriately positioned within the appropriate central venous location. Considering that catheters range from 10 cm to 30 cm in length and are inserted 1-5 cm below the skin's surface and 1-2 cm distal to the entry point, proper placement will result in the tip being in a central vein. Therefore, there is no clinical necessity or coding/documentation requirement to confirm the tip's location.

Intraosseous access is the insertion of a needle into the bone marrow cavity, typically in the proximal tibia or humerus. This method is used in emergencies where traditional means cannot obtain vascular access. Intraosseous access is primarily used for resuscitation in critically ill or injured patients, allowing for the rapid administration of medications and fluids. It is a valuable option in situations where time is of the essence, such as cardiac arrest or severe trauma.

Intraosseous access requires more skill and expertise than routine peripheral IV access. It is typically performed by the ED physician/QHP or under their direct supervision by a specifically trained provider.  Placement of an intraosseous line by a physician/QHP is reported with CPT code 36680 - Placement of needle for intraosseous infusion.

For a procedure performed in the emergency department, a procedure note is necessary. This note should include the reason, details like site, method, and instrument size, evidence of completion, and any complications encountered. Notate ultrasound guidance when applicable and confirm image saving.

Yes. The use of ultrasound guidance during vascular access procedures has become common due to its numerous benefits, including increased success rates, decreased complications, and improved patient outcomes.  CPT code 76937 should be reported in addition to the primary procedure code, as it represents the additional work and resources required for ultrasound-guided access.

• 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)

Physicians/QHPs and coders must understand the unique aspects of this code to ensure proper coding. Firstly, it is essential to note that the code is specifically intended for the "dynamic" technique, where ultrasound is used throughout the procedure, from identifying the vessel to visualizing the needle entering it. This technique requires a permanently recorded image, which is a key requirement for coding purposes.

On the other hand, the "static" technique, where ultrasound is only used to identify the vessel but not during line placement, does not fulfill the requirements for CPT code 76937. It is essential to differentiate between these two techniques to ensure accurate coding and appropriate reimbursement.

While the CPT description indicates the need for an image of the target vessel, it does not explicitly require an image or video of the needle entering the vessel. Obtaining an image mid-procedure could potentially compromise patient safety, as it would divert the operator's attention from the procedure. Therefore, it is recommended to focus on obtaining a permanent recording of the selected vessel or the needle in the vessel once it is feasible and safe.

While a pre-cannulation image of the target vessel is acceptable, having a permanently recorded post-procedural image or video of the catheter in the vessel once the line is secure is preferable.

The documentation must include not only the specifics of the line placement but also the integral use of ultrasound guidance, as mandated by CPT guidelines. Continuous ultrasound use during the procedure is necessary, and a permanently recorded image or video is a requirement for coding. In addition to the details of the central line, a combined procedure note for an ultrasound-guided central line insertion may also include details, such as:

• Ultrasound Guidance: An ultrasound probe was utilized to identify the XXXX vein and assess its patency and appropriate caliber for cannulation. The vein was located and, under real-time ultrasound guidance, XXXX vein cannulated; venous entry was confirmed by blood aspiration. Post-procedure, a permanent Image with visualization of the catheter in the vein saved to patient medical record.

Note: Local hospital or payer policy may require a physician/QHP's order to ensure appropriate reimbursement for the use of the ultrasound. See ACEP’s FAQ for further information concerning the use of ultrasound in the emergency department.

Arterial catheters may be preferred when accurate and real-time blood pressure monitoring is essential or when frequent blood gas sampling is needed. Arterial puncture is specifically utilized when arterial blood gas analysis is required.

Arterial puncture is usually performed by respiratory therapists or other ancillary staff, but if the ED physician/QHP draws arterial blood for testing, CPT code 36600 would be reported.

• 36600, Arterial puncture, withdrawal of blood for diagnosis

If the ED physician/QHP inserts an arterial catheter (A-line) into an artery, CPT code 36620 would be reported.

• 36620, Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous.

As detailed in FAQs 7 and 8 above, appropriate documentation code 76937 may also be reported if ultrasound guidance was used to insert the arterial line.

• 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)

Report CPT code 36625 to report if the A-line procedure is performed via cutdown. However, cutdown procedures performed by emergency department physicians/QHPs have significantly diminished. Consequently, the utilization of this code by ED physicians/QHPs is now relatively uncommon.

A peripherally inserted central catheter, or PICC line, is inserted into a vein in the basilic or cephalic vein of the arm and advanced into the superior vena cava above the right atrium.  PICC lines are most frequently placed by specialized nurses; however, on occasion, an emergency physician/QHP may place a PICC line. PICC lines are commonly used in the emergency department to provide long-term access for medications, fluids, blood products, and other therapies when a patient requires ongoing intravenous therapy that cannot be effectively delivered through a regular peripheral IV line. This could include situations such as prolonged antibiotic treatment, chemotherapy, or the need for frequent blood draws. The procedure can be done at the bedside, minimizing the need for more invasive procedures and reducing the risk of complications associated with repeated peripheral IV insertions.

In 2019, several changes affected the correct coding for PICC lines. Before CPT 2019, codes 36568 and 36569 were used to report all PICC insertions. However, as of 2019, these codes were revised to describe PICC insertion performed without imaging guidance and codes 36572 and 36573 were created to report PICC insertion performed with imaging guidance.

When the PICC line is placed without imaging guidance by a physician/QHP, 36568 or 36569 would be reported.

• 36568 - Insertion of a peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, without imaging guidance; younger than 5 years of age
• 36569 - Insertion of a peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, without imaging guidance; age 5 years or older

When a PICC line is placed with imaging guidance by a physician/QHP, 36572 or 36573 would be reported:

• 36572 - Insertion of a 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
• 36573 - Insertion of a 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 codes 36572 and 36573, all image documentation and radiological supervision and interpretation are included and required to report the procedures. When ultrasound guidance is performed, the following should be documented:

• Evaluation of the potential puncture sites
• Patency of the entry vein
• Real-time ultrasound visualization of needle entry into the vein; and
• Image documentation (representative images from all modalities used are stored in the patient's permanent record).

Note that imaging to document the final catheter position or to confirm the location of the catheter tip is not reported separately because all necessary imaging is included in codes for the PICC line.

Similar to other vascular access procedures, clinically relevant details should be documented. If ultrasound guidance was employed, notate as much with “under real-time ultrasound guidance” type statements and confirm that images have been saved.

Yes. A newborn's umbilical cord generally has two umbilical arteries and one umbilical vein.

To report catheterization of the vein report:

• 36510 - Catheterization of umbilical vein for diagnosis or therapy, newborn.

To report catheterization of an umbilical artery use:

• 36660 – Catheterization, umbilical artery, newborn, for diagnosis or therapy.

As with other vascular access procedures, a procedure note including clinically relevant details should be documented.