Please note this question was answered in 2019. The coding advice may or may not be outdated.
Documentation requirement to use CPT 36556
Question:
This is a profee coding question in a teaching facility setting. Physician A (general surgeon) places a CVC at bedside without imaging guidance. We assume that the tip cannot be confirmed at bedside because the final position is not documented, although CXR is ordered by Physician A. Physician B (radiologist) then reads the CXR and confirms that the tip is in the correct central vasculature. Is this enough documentation to support 36556 (the op note without tip confirmation and CXR confirming tip position, that is)? Or do we still need Physician A to document that he/she reviewed the CXR to confirm final placement in order to report cpt 36556 in full (without modifier 52)?
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