Art lines

[Random Anesthesiologist]

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Residents don't bill for anything, or even touch any of the billing sheets, at least at any hospital I've been at! Thank God that is somebody else's job. We just take care of the patients 😛 And fill out >12 review of system elements, heh

That ROS - people die left and right if it's not specifically included in your note 😉

 

[deleted162650]

As far as I know, you cannot bill for U/S guidance for a-line placement. Well you can, but I don't hink you will get paid for it. Yes U/S is one extra unit for CVL placement , but our billing sheets specifically say not to bill U/S in conjunction with A-line placement. Maybe it's region specific?

 

[urge]

As far as I know, you cannot bill for U/S guidance for a-line placement. Well you can, but I don't hink you will get paid for it. Yes U/S is one extra unit for CVL placement , but our billing sheets specifically say not to bill U/S in conjunction with A-line placement. Maybe it's region specific?

Cpt code 76937 used for central lines and arterial lines.

Look it up.

PS: I want my 10% finders fee.

 

[Dwindlin]

Okay, so with all this billing talk what is the bottom line for me as a resident? I often do these (and central lines) unsupervised, for art lines I will occasionally grab the ultrasound if someone else already had difficulty of I am having trouble and I always use it for IJs. We don't save images or record names in the machine (not even sure we can), and our line note is pretty generic, if I use ultrasound I just add a line that says "under ultrasound guidance." Should I stop putting that in my note then (even though I did use the damn thing)?

 

[pgg]

If you used the ultrasound, document it in your note. Always document what you did. Billing is a separate issue.

 

[Bostonredsox]

I print pics and put them in the chart. And by that I mean nurse prints them out and tapes them into the chart while I'm finishing the line. I don't enter names in the machine. So no extra time for me. And for billing I dictate
Procedure 1: us guided imaging of jugular venous systems
Procedure 2 placement of right ij CVC under direct us guidance.

A line I haven't been doing this because I was under the impression there is no change in billing for using us. Will start adding that to dictation.

 

[urge]

If you used the ultrasound, document it in your note. Always document what you did. Billing is a separate issue.

It depends on whether the billing company bills from your notes or not. With computerized record I can tell you that the moment you document US use the billing company will take it from there.

If billing is from a separate sheet, then it is up to what you mark there and the procedure note has no bearing in the billing.

Be careful guys.

 

[urge]

I print pics and put them in the chart. And by that I mean nurse prints them out and tapes them into the chart while I'm finishing the line. I don't enter names in the machine. So no extra time for me. And for billing I dictate
Procedure 1: us guided imaging of jugular venous systems
Procedure 2 placement of right ij CVC under direct us guidance.

A line I haven't been doing this because I was under the impression there is no change in billing for using us. Will start adding that to dictation.

I accept paypal...

 

[Dwindlin]

It depends on whether the billing company bills from your notes or not. With computerized record I can tell you that the moment you document US use the billing company will take it from there.

If billing is from a separate sheet, then it is up to what you mark there and the procedure note has no bearing in the billing.

Be careful guys.

I have no idea how we bill. I can say that I don't ever fill out any billing sheets, just drop my note. I have no clue if the attendings fill them out afterwards. Guess I should ask. . .

 

[Mman]

I have no idea how we bill. I can say that I don't ever fill out any billing sheets, just drop my note. I have no clue if the attendings fill them out afterwards. Guess I should ask. . .

As a general rule of thumb, academic departments are terrible about billing. Conservative estimate is they probably miss something like 20% of charges. The problem is nobody cares because nobody's pay changes if they bill better.

 

[periopdoc]

If you aren't billing for it, then somebody is losing money. Maybe you, maybe your institution. It just depends on how you bill and are payed. If you aren't maximizing legitimate billing for your institution, then you are doing a dis-service to your institution. If I use it, then I get a picture, and I bill.

There is no need to enter patient data, although it certainly is a nice preventative measure should you ever be audited. As long as a picture is taken and is placed in the chart with your interpretation, then you are ok. Most anesthesia machines provide a date/ time stamp on the printout. Make sure that the clock is right.

U/S takes me an additional 1-2 min over a routine a-line placement if the machine is already in the OR when I start (like it is in our heart room). I know because I literally document start and stop times for any pre-induction procedures performed in the OR (and so should you as this time has to be subtracted from your anesthesia time. You can't simultaneously bill for the time and the procedure prior to induction).

My routine is to palpate a pulse and make an attempt without U/S. How quickly I call for U/S depends on the pulse characteristics and the proximity of the U/S. Sometimes I can tell it is going to be a tough stick and I go straight to U/S after missing once. Sometimes I will give it 2-3 tries before I go to U/S. Usually the a-line is in in under 3 min. Longest in-OR placement in the last 3 years was 7 min. Lowest documented systolic pressure at placement of aline by palpation was 43 (one of my partners was doing the anesthesia and I was asked to come in and get an a-line). I am sure that having said that, my next a-line will be in a 18-year-old with a SBP >180 and a bounding pulse and it will take me 30 min.

-pod

 

[deleted162650]

Urge, I know the 76937 code. You cannot bill 76937 in conjunction with 36620 (art line code). It says this specifically on our billing sheets.

Look it up 😉

 

[urge]

Urge, I know the 76937 code. You cannot bill 76937 in conjunction with 36620 (art line code). It says this specifically on our billing sheets.

Look it up 😉

You need a better billing company.

Medicare doesn't allow it but private ins does.

You need a better billing company.

 

[deleted87051]

Urge, I know the 76937 code. You cannot bill 76937 in conjunction with 36620 (art line code). It says this specifically on our billing sheets.

Look it up 😉

We've been told the same thing. Perhaps there is regional variation.

 

[deleted162650]

Actually what I need is a better payer mix. Our billing company actually does a very good job for us given what they have to work with.

Off the top of my head I bet that every A-line I've needed U/S for has been either a medicare or medicaid patient.

 

[OB1🤙]

So in my heart room I have the hockey-stick ultrasound on the TEE machine sitting there anyway, so I started using it for all my cardiac a-lines after a few ESRD vasculopathic nightmares.

Before the patient comes in the room, I put some goop and then a Tegaderm on the probe.

Patient comes in, transfers, arm out. Bringing the machine from the wall to the bed is the only time added to the procedure- 5 seconds if that.

Go around, paint the forearm with chlorhexidine. The chlorhex serves as the ultrasound medium- no need for sterile gel. Pick up probe with left hand (I don't use sterile gloves for a-lines, because I don't for PIVs either and I'm in the camp that considers them equivalent in infection risk, just don't touch the actual line (duh)). Scan forearm for most proximal reasonable landing zone. Inject lido with the probe still on. I put another dollop of chloraprep for good measure. Go in with the Arrow kit. Enter vessel, put probe down, thread wire with now-free left hand. Done once, done right, done fast.

This saves huge time IMO in the vasculopaths. And since it's sitting there anyway, I figure why not use it for everyone and get the first-pass success close to 100%.

And I'm in agreement that a radial line placed as proximally as is reasonable is much more reliable, less kink-prone, and doesn't do the damp-after-CPB thing.

 

[Random Anesthesiologist]

Ok, now, does anyone have advice specific to placing an art line on a patient *after* they've been tanked up with Levo +/- vaso, neo, epi, dopamine?

This is the population on which I have the most trouble with radial lines. The common consult entails being on 1+ pressor for days and they just now "can't get a cuff pressure". Not to mention a lot of the time they're doing this through a peripheral vein (omg) so I end up placing a cvl too. I take a look with ultrasound and the artery is so small. I can get blood return but just can't thread the darn catheters. Maybe the kit catheter is just too big in these cases...

I just wish they'd call me right away to do this for these really sick folks instead of waiting so long.

Oh, I should mention, one of the hospitals I rotate at does not have the pre-wired arrow kit. That place has the all-in-one radial/femoral kit. And, we are required to be full head-to-toe sterile with draped sterile field. For all art lines. Plus probe covers if we use the us. I kid you not.

 

[Bostonredsox]

Ok, now, does anyone have advice specific to placing an art line on a patient *after* they've been tanked up with Levo +/- vaso, neo, epi, dopamine?

This is the population on which I have the most trouble with radial lines. The common consult entails being on 1+ pressor for days and they just now "can't get a cuff pressure". Not to mention a lot of the time they're doing this through a peripheral vein (omg) so I end up placing a cvl too. I take a look with ultrasound and the artery is so small. I can get blood return but just can't thread the darn catheters. Maybe the kit catheter is just too big in these cases...

I just wish they'd call me right away to do this for these really sick folks instead of waiting so long.

Oh, I should mention, one of the hospitals I rotate at does not have the pre-wired arrow kit. That place has the all-in-one radial/femoral kit. And, we are required to be full head-to-toe sterile with draped sterile field. For all art lines. Plus probe covers if we use the us. I kid you not.

Most of my art lines are patients already on multiple vasopressors from the Ed. In that case I usually go right to the US.

If they are so clamped I can't get the arrow wire into the radial even with us, rarely happens, stick the groin.

 

[Random Anesthesiologist]

Most of my art lines are patients already on multiple vasopressors from the Ed. In that case I usually go right to the US.

If they are so clamped I can't get the arrow wire into the radial even with us, rarely happens, stick the groin.

Of course I stick the groin, and that's easy. I think I answered myself in trying to use a smaller catheter.

 

[periopdoc]

These are tough. U/S is your friend and the Arrow cath isn't. I use a 21 or 22 gauge micropuncture needle with appropriately sized wire and catheter for these. Frequently you won't get blood return so I don't watch for it. Introduce the needle and thread the wire with real-time visualization. Often this requires a third sterile hand. When you see the wire threading up the lumen of the artery then you are golden. Of course that doesn't guarantee that the line will work for very long.

There is always brachial or femoral.

I am pretty anal about sterility on these as the patient is behind the eight ball already, you know it isn't going to be a quick stick and done, you know it is going to be in for a long time, and you know you are going to be manipulating a lot of things during the procedure. Prep/small drape/probe cover/sterile gloves. I am always wearing a scrub cap and mask in the hospital so I guess I use them too although I wouldn't be too picky about that.

- pod

 

[Random Anesthesiologist]

Thanks pod. We are not allowed to do brachials here, although I did do one on someone who died a few hours later from sepsis a couple months ago. It was my only option, she was a bilateral amputee at the hip and radials/ulnars were barely visible on us.

Thanks for the micro puncture tip.

 

[Dwindlin]

Thanks pod. We are not allowed to do brachials here, although I did do one on someone who died a few hours later from sepsis a couple months ago. It was my only option, she was a bilateral amputee at the hip and radials/ulnars were barely visible on us.

Thanks for the micro puncture tip.

Why? Not that it surprises me, as has been seen my current place does some strange, unnecessary things. Just curious if there is a rationale.

 

[Random Anesthesiologist]

Why? Not that it surprises me, as has been seen my current place does some strange, unnecessary things. Just curious if there is a rationale.

The rationale they use is increased risk of arterial occlusion downstream and subsequent ischemia and/or hematoma compression of median and ulnar nerves. Then I talk to anesthesiologists who say they routinely do them! 🙂

 

[Bostonredsox]

The rationale they use is increased risk of arterial occlusion downstream and subsequent ischemia and/or hematoma compression of median and ulnar nerves. Then I talk to anesthesiologists who say they routinely do them! 🙂

Have done 2-3 brachials. The risk of downstream occlusion is real though, so if there going to be a long term ICU art line and you absolutely can't get radial, I tend to convert brachial to fem.