Tunneled Dialysis Catheter (Permcath)
3655876937wRVU: 0.29 — Ultrasound guidance for vascular access, image documentation and permanent record (add-on, separately reportable with 36558; 0.29 wRVU; requires documented real-time imaging and permanent image record)77001wRVU: 0.37 — Fluoroscopic guidance for central venous access device placement, repositioning, or replacement (add-on, separately reportable with 36558; 0.37 wRVU; requires permanent fluoroscopic image of final catheter tip position)
End-stage renal disease requiring hemodialysis; no usable AV access; tunneled hemodialysis catheter for dialysis initiation
Same
Right [left] internal jugular vein tunneled hemodialysis catheter (Permcath) placement
[Attending name], MD/DO
[Resident/PA name]
Local: [X] mL 1% lidocaine [with epinephrine at tunnel site / plain at access site] [/ MAC]
The patient is a [age]-year-old [male/female] with end-stage renal disease requiring urgent initiation of hemodialysis. [AV fistula / graft is not yet mature / no suitable access sites / maturing fistula not yet cannulatable.] A tunneled hemodialysis catheter was placed as a bridge to permanent access. The risks, benefits, and alternatives were discussed and informed consent was obtained.
The right internal jugular vein was patent and compressible on ultrasound. The catheter tip was confirmed by fluoroscopy at the [cavoatrial junction / right atrium]. Blood flow rates of [350-400 mL/min] were confirmed. No pneumothorax on post-procedure chest X-ray [/ fluoroscopic imaging showed no pneumothorax].
The patient was positioned supine in Trendelenburg with the head turned to the left. The right neck, chest, and anterior chest wall were prepped and draped in sterile fashion. Local anesthesia was infiltrated at the right internal jugular vein access site and along the planned subcutaneous tunnel.
Under real-time ultrasound guidance, the right internal jugular vein was accessed with an [18-gauge] needle. A permanent image was obtained documenting real-time ultrasound-guided venous access. A [0.035-inch] guidewire was advanced into the superior vena cava under fluoroscopic guidance. The wire position was confirmed in the SVC. The skin was incised and the tract dilated.
The subcutaneous tunnel was created using the tunneling device from the anterior chest wall exit site to the venous access site. The [15.5 Fr] [Mahurkar / HemoSplit / Palindrome] tunneled catheter was pulled through the tunnel so the Dacron cuff lay in the subcutaneous tunnel [approximately 1-2 cm from the exit site].
The peel-away sheath was advanced over the wire under fluoroscopy and the catheter was inserted through the sheath into the SVC. The catheter tip was positioned under fluoroscopy at the [cavoatrial junction / right atrium]. The peel-away sheath was removed. A permanent fluoroscopic image was obtained documenting final catheter tip position at the cavoatrial junction. The catheter was sutured to the skin at the exit site with [3-0 Prolene] and locked with [heparin 1000 units/mL / 4% sodium citrate] solution.
Both lumens were aspirated and flushed; brisk blood return and flush without resistance confirmed. Post-procedure chest X-ray was obtained confirming [catheter tip position / no pneumothorax].
None
None
Minimal
None
The patient tolerated the procedure well. Both catheter lumens were functioning with brisk blood return. The catheter was ready for immediate dialysis use. Dialysis nursing was notified. AV access planning was discussed for long-term transition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ESRD, dialysis initiation, no mature AV access
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right *** tunneled hemodialysis catheter placement
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Local [with MAC]
INDICATIONS: .PTAGE-year-old .PTSEX with ESRD requiring dialysis. ***. Consent obtained.
FINDINGS: Right IJV patent on ultrasound. Catheter tip at cavoatrial junction on fluoroscopy. Both lumens functional. No pneumothorax on post-procedure imaging.
PROCEDURE:
Supine, Trendelenburg, head left. Right neck/chest prepped. Local anesthesia infiltrated. Real-time ultrasound-guided right IJV access, 18-gauge needle; permanent ultrasound image obtained. Wire into SVC, fluoroscopy confirmed. Tract dilated. Tunnel created, anterior chest to access site. *** Fr *** catheter pulled through tunnel, cuff 1-2 cm from exit. Peel-away sheath, catheter advanced to cavoatrial junction under fluoroscopy. Permanent fluoroscopic image of tip position obtained. Sheath removed. Secured with 3-0 Prolene. Locked with ***. Both lumens aspirated; brisk return. Post-procedure CXR: tip at CAJ, no pneumothorax.
EBL: Minimal
COMPLICATIONS: None
DISPOSITION: Both lumens functional. Dialysis notified.
Signed: .ME, .MYDEGREE
.TODAYVariants
Tunneled Catheter Exchange Over Wire
The existing dysfunctional tunneled catheter was exchanged over a guidewire. The cuff was freed from the subcutaneous tunnel using blunt dissection. A [0.035-inch] wire was advanced through the existing catheter into the SVC under fluoroscopy. The old catheter was removed over the wire. A new [15.5 Fr] tunneled catheter was placed through a new subcutaneous tunnel [or the same tunnel if not infected]. The tip was repositioned at the cavoatrial junction under fluoroscopy. Catheter exchange (CPT 36581, 3.15 wRVU) is appropriate for catheter dysfunction without infection; a new tunnel site is required if catheter-related bloodstream infection is present.
Femoral Tunneled Catheter (IJ/Subclavian Exhausted)
Given bilateral internal jugular and subclavian occlusion on prior imaging, the right [left] femoral vein was used for access. The catheter was tunneled from the femoral exit site along the medial thigh. The tip was positioned in the inferior vena cava at the level of the [iliac confluence / right atrium via IVC]. Femoral catheters carry higher infection rates and are associated with ipsilateral DVT; this approach was used given lack of upper body venous access.
Charting Tips
- Document catheter tip position specifically. 'Cavoatrial junction' or 'right atrium' is required. Catheter tip in the SVC (too proximal) results in inadequate flow rates and high recirculation. Tip in the right ventricle risks arrhythmia. Document the fluoroscopic landmark used for tip placement.
- Document both lumens aspirating with brisk blood return before leaving the room. A tunneled catheter that does not aspirate freely at insertion will not function for dialysis and requires repositioning or replacement before the patient returns for their session.
- Document the cuff position in the tunnel. The Dacron cuff should be 1-2 cm from the exit site. A cuff too close to the skin surface will extrude; a cuff too deep may not anchor adequately. This detail matters if the patient later develops cuff extrusion.
- To bill 76937 and 77001 separately, the note must document: (1) real-time ultrasound imaging was performed for vascular access, and (2) a permanent image was saved to the medical record. Without documentation of the permanent image, the codes will be denied.
Billing Tips
- 36558 (tunneled centrally inserted central venous catheter, without subcutaneous port or pump, age ≥5; 4.48 wRVU, 10-day global) is the standard code for a single dual-lumen tunneled hemodialysis catheter (PermCath, Palindrome, HemoSplit). 36560 (with subcutaneous port, age 5 through 18; 5.89 wRVU) and 36561 (with subcutaneous port, age ≥5; 5.65 wRVU) are for implanted port devices — these have ports, which dialysis catheters do not. Use 36558 for any tunneled hemodialysis catheter without a subcutaneous port.
- Twin-catheter (Tesio) systems: 36565 (two catheters via two separate venous access sites, without subcutaneous port; 5.65 wRVU, 10-day global) is the correct code for Tesio-type catheters. 36566 (same configuration but with subcutaneous ports; 6.13 wRVU) is for twin catheters WITH ports — not the standard Tesio. Do not use 36566 for a standard Tesio.
- Fibrin sheath removal: CPT 36595 (mechanical removal of pericatheter fibrin sheath; 3.50 wRVU, 0-day global) is the correct code for fibrin sheath stripping performed to restore catheter function. CPT 36563 (tunneled catheter with subcutaneous pump; 5.84 wRVU) describes a different procedure entirely — do not use 36563 for fibrin sheath management.
- Replacement of existing tunneled catheter: 36581 (without port; 3.15 wRVU) for exchange of an existing tunneled hemodialysis catheter. 36582 (with port; 4.87 wRVU) is for exchange of a tunneled catheter with subcutaneous port — not applicable to standard dialysis catheter exchange.
- Imaging guidance is separately reportable with 36558 — it is NOT bundled. 76937 (ultrasound guidance, 0.29 wRVU) is separately reportable when real-time imaging was used and a permanent image record is documented. 77001 (fluoroscopic guidance, 0.37 wRVU) is separately reportable when a permanent fluoroscopic image of the final catheter tip position is documented. Both require documentation of the permanent image. This distinction from PICC placement codes (36568/36569/36572/36573/36584), where imaging IS bundled, is a common source of under-billing.
- Global period is 10 days (minor). Routine post-placement care, suture removal, and catheter flushes within 10 days are bundled. Fibrin sheath removal or catheter exchange after 10 days is separately billable.
- Document access site, vein used (right IJ, subclavian, femoral), laterality, catheter brand/size/length, tip position on fluoroscopy (cavoatrial junction), and indication (ESRD, bridge to maturation). ICD-10: N18.6 (ESRD) + Z99.2 (dependence on renal dialysis) are both required for CMS ESRD network reporting. For AKI requiring temporary dialysis, use N17.9 (AKI, unspecified) as primary.
General coding reference. Verify with your institution’s billing department before submitting claims.