Peripherally Inserted Central Catheter (PICC)
3657336569wRVU: 1.85 — PICC, age 5 or older, WITHOUT imaging guidance — alternative primary when no ultrasound or fluoroscopy is used (1.85 wRVU, 0-day global)36572wRVU: 1.77 — PICC, younger than 5 years, WITH imaging guidance — age-based alternative primary (1.77 wRVU, 0-day global)36568wRVU: 2.06 — PICC, younger than 5 years, WITHOUT imaging guidance — age-based alternative primary (2.06 wRVU, 0-day global)
Need for durable central venous access / [indication: prolonged IV antibiotics / chemotherapy / parenteral nutrition / frequent blood draws / inadequate peripheral access]
Same
Ultrasound-guided placement of [single / double / triple]-lumen peripherally inserted central catheter, [right / left] [basilic] vein
[***, MD/DO]
[Nurse/tech name]
Local: [X] mL 1% lidocaine without epinephrine
The patient is a [age]-year-old [male / female] requiring central venous access for [prolonged antibiotics / chemotherapy / parenteral nutrition / frequent phlebotomy] with [inadequate / exhausted] peripheral options. The risks, benefits, and alternatives were discussed with the patient [or surrogate], and informed consent was obtained.
The [right / left] [basilic] vein was patent, compressible, and non-thrombosed on ultrasound, measuring approximately [___] mm. The selected vein accommodated the catheter with a catheter-to-vein ratio of approximately [___]% (target 45% or less). The catheter tip was positioned at the cavoatrial junction, confirmed by [real-time ECG tip navigation / post-procedure chest radiograph]. [No arterial puncture, arrhythmia, or malposition was encountered.]
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 and draped, and maximal 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 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 for brisk venous return and flushed with saline. The catheter was secured with a [sutureless securement device / subcutaneous anchor] and a sterile occlusive dressing was applied. The external length was recorded.
None
None
Minimal
None
The patient tolerated the procedure well and returned to [floor / step-down / ICU] care in stable condition. The catheter was [ready for use / to be used after radiographic tip confirmation].
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Need for central venous access, ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Ultrasound-guided *** PICC placement, *** basilic vein
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Local: *** mL 1% lidocaine without epinephrine
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX requiring central venous access for ***. Peripheral access inadequate. Risks, benefits, and alternatives discussed and informed consent obtained.
FINDINGS: *** basilic vein patent and non-thrombosed on ultrasound, *** mm. Catheter-to-vein ratio *** % (target <=45%). Tip at cavoatrial junction, confirmed by ***.
PROCEDURE:
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 and draped; maximal 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 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 dressing. External length recorded.
COMPLICATIONS: None
EBL: Minimal
DISPOSITION: Patient tolerated procedure well, stable condition.
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 the tallest biphasic P wave. When a positive ECG confirmation is obtained, 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.
Small Vein / Catheter-to-Vein Ratio Concern
The initial target vein measured [___] mm, giving a catheter-to-vein ratio above 45%. To reduce the risk of catheter-associated thrombosis, a [larger / more proximal] vein was selected [or a smaller-caliber catheter or reduced lumen count was used]. The final ratio was approximately [___]%. Document the vein diameter, catheter French size, and the resulting ratio.
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. Fluoroscopic guidance is included in 36573 and is not separately reported.
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.
- 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. If any imaging guidance is used, the correct code is 36573 (with imaging), and separate ultrasound-guidance billing (76937) 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.
Billing Tips
- Bill 36573 for PICC placement in a patient 5 years or older when any imaging guidance is used (1.66 wRVU, 0-day global). Ultrasound for venous access, fluoroscopy, image documentation, and the associated radiologic supervision and interpretation are all bundled into 36573. Do not separately report ultrasound guidance (76937) or fluoroscopic guidance alongside it.
- Bill 36569 only when the PICC is placed with no imaging guidance at all (1.85 wRVU, 0-day global). If ultrasound is used to find the vein or imaging is used to confirm the tip, the correct code is 36573, not 36569. 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. Patients younger than 5 use 36572 (with imaging) or 36568 (without imaging). 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 with modifier -25 when documented independently.
- 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 using 36569 or 36573.
- 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.
General coding reference. Verify with your institution’s billing department before submitting claims.