Peripherally Inserted Central Catheter (PICC)
Ultrasound-guided [single / double / triple]-lumen peripherally inserted central catheter placement, [right / left] [basilic] vein
[indication] requiring durable central venous access for [prolonged IV antibiotics / chemotherapy / parenteral nutrition / frequent phlebotomy], with [inadequate / exhausted] peripheral access.
[Informed consent was obtained from the [patient / patient's surrogate] after discussion of risks, benefits, and alternatives / The procedure was emergent, and consent was implied].
[***, MD/DO]
Local: [X] mL 1% lidocaine without epinephrine
The [right / left] [basilic] vein was patent, compressible, and non-thrombosed on ultrasound, measuring approximately [X] mm, for a catheter-to-vein ratio of approximately [X]%. [No arterial puncture, arrhythmia, or malposition was encountered.]
A time-out was completed confirming the patient, procedure, and side. The patient was placed supine with the [right / left] arm abducted on an armboard. The upper arm was surveyed with ultrasound, and the [basilic] vein was selected above the antecubital fossa for its caliber and distance from the brachial artery and median nerve. The insertion length was measured from the planned puncture site to the right sternoclavicular joint and down to the third intercostal space to estimate the cavoatrial junction.
A tourniquet was applied. The arm was prepped with chlorhexidine and draped in sterile fashion. Maximum sterile barrier precautions were used, including sterile gown, gloves, full drape, mask, and cap. The skin over the vein was anesthetized with [X] mL of 1% lidocaine.
Under real-time ultrasound guidance, a micropuncture needle was advanced into the [basilic] vein with return of venous blood. A guidewire was passed without resistance, and the needle was exchanged for a peel-away introducer over a dilator using the modified Seldinger technique. The tourniquet was released. The catheter, trimmed to the premeasured length, was advanced through the introducer to the cavoatrial junction with the patient's head turned toward the access side to discourage passage into the internal jugular vein.
The peel-away sheath was removed. Tip position at the cavoatrial junction was confirmed by [real-time ECG tip navigation / a post-procedure chest radiograph]. All lumens were aspirated with brisk venous return and flushed with saline. The catheter was secured with [a sutureless securement device / a subcutaneous anchor], and a sterile occlusive dressing was applied.
[X] Fr [single / double / triple]-lumen PICC, [right / left] [basilic] vein, inserted length [X] cm, external length [X] cm, tip at the cavoatrial junction confirmed by [real-time ECG tip navigation / chest radiograph], secured with [a sutureless securement device / a subcutaneous anchor]
Minimal
None
None
The patient tolerated the procedure well and returned to [floor / step-down unit / ICU] care in stable condition. The catheter is [cleared for use / to be used after radiographic tip confirmation].
Epic SmartPhrase Version
PROCEDURE: Ultrasound-guided *** lumen PICC placement, *** basilic vein
INDICATION: *** requiring durable central venous access for ***, with inadequate peripheral access.
CONSENT: [Informed consent obtained from the [patient / surrogate] after discussion of risks, benefits, and alternatives / Emergent, consent implied].
PERFORMED BY: ***, MD/DO
ANESTHESIA: Local: *** mL 1% lidocaine without epinephrine
FINDINGS: *** basilic vein patent, compressible, and non-thrombosed on ultrasound, *** mm. Catheter-to-vein ratio *** %. No arterial puncture, arrhythmia, or malposition.
PROCEDURE DETAILS:
Time-out completed. Supine, arm abducted. Ultrasound survey; *** basilic vein selected above the antecubital fossa, away from the brachial artery and median nerve. Insertion length measured to the sternoclavicular joint and third intercostal space. Tourniquet applied. Arm prepped with chlorhexidine and draped. Maximum sterile barrier precautions used. Skin anesthetized with *** mL 1% lidocaine.
Under real-time ultrasound, micropuncture access to the *** basilic vein with venous return. Guidewire passed without resistance. Peel-away introducer placed over a dilator (modified Seldinger). Tourniquet released. Catheter trimmed to premeasured length and advanced to the cavoatrial junction with the head turned toward the access side. Sheath peeled away. Tip confirmed at the cavoatrial junction by ***. All lumens aspirated and flushed. Secured with *** and sterile occlusive dressing.
DEVICE PLACED: *** Fr *** lumen PICC, *** basilic vein, inserted length *** cm, external length *** cm, tip at cavoatrial junction by ***, secured with ***
EBL: Minimal
SPECIMENS: None
COMPLICATIONS: None
POST-PROCEDURE PLAN: Tolerated well, stable condition. Catheter [cleared for use / to be used after radiographic tip confirmation].
Signed: .ME, .MYDEGREE
.TODAYVariants
ECG-Guided Tip Confirmation (No Confirmatory CXR)
Tip location was guided in real time using the intravascular ECG method [Sherlock 3CG / equivalent]. A maximal P-wave deflection was observed as the tip approached the cavoatrial junction, and the catheter was set at the point of maximal P-wave amplitude, before a negative P-wave deflection appeared. ECG tip confirmation was positive, and the catheter was cleared for use without a confirmatory chest radiograph.
Small Vein / Catheter-to-Vein Ratio Concern
The initial target vein measured [X] mm, giving a catheter-to-vein ratio above 45%. [A [larger / more proximal] vein was selected / A smaller-caliber catheter was used / The lumen count was reduced]. The final ratio was approximately [X]%.
Fluoroscopic Placement (Malposition or Difficult Anatomy)
Because of [prior catheter history / difficult venous anatomy / initial malposition into the internal jugular vein], placement was completed under fluoroscopic guidance. The catheter course was followed to the superior vena cava and the tip set at the cavoatrial junction under direct visualization.
Charting Tips
- Document the vein diameter and the catheter-to-vein ratio. A ratio of 45% or less is the accepted target to limit catheter-associated venous thrombosis. Record the vein size, the catheter French size, and the resulting ratio, especially when a smaller vein forced a change in catheter choice.
- With a positive real-time ECG tip confirmation, a confirmatory chest radiograph is not required and the catheter may be used immediately. Document the P-wave finding and that ECG confirmation was positive.
- Document how imaging guidance was used, because it determines the code. State that ultrasound was used for venous access and how the tip was confirmed. Any imaging guidance makes the imaging-inclusive PICC service correct, and separate ultrasound-guidance billing is not appropriate.
- Document the tip position and the confirmation method. State that the tip lies at the cavoatrial junction and whether confirmation was by real-time ECG tip navigation or a post-procedure chest radiograph. A tip that ends short of the superior vena cava is a midline, not a PICC, and cannot be reported with the PICC codes.
- Document maximal sterile barrier precautions (gown, gloves, full drape, cap, mask). This is a central-line bundle requirement audited by infection control for CLABSI prevention.
Documentation & Reimbursement Considerations
- Primary service: Report Peripherally Inserted Central Catheter (PICC) as the primary service when it is the definitive operation performed.
- PICC placement in a patient 5 years or older with any imaging guidance is a single imaging-inclusive service (1.66 wRVU, 0-day global). Ultrasound for venous access, fluoroscopy, image documentation, and the associated radiologic supervision and interpretation are all bundled into it. Do not separately report ultrasound or fluoroscopic guidance alongside it.
- The PICC service without imaging (1.85 wRVU, 0-day global) applies only when no imaging guidance is used at all. If ultrasound is used to find the vein or imaging is used to confirm the tip, report the imaging-inclusive service. The imaging-inclusive codes carry a slightly lower work RVU because guidance was folded into the code family in the 2019 revision.
- Age at the time of service sets the code pair, with separate with-imaging and without-imaging services for patients younger than 5. Document the patient's age and the guidance actually used.
- 0-day global period: no bundled postoperative window. A significant, separately identifiable E/M service on the same day may be reported when documented independently, with the appropriate modifier appended to the E/M.
- A midline catheter, whose tip ends in the axillary or subclavian vein short of the superior vena cava, is not a central line and is not reported with the PICC codes. Confirm a central tip at the cavoatrial junction before reporting a PICC.
- Document the tip-confirmation method (real-time ECG-based tip location or a post-procedure chest radiograph) and the final tip position. Confirmation is part of the insertion service and is not billed separately.