Ask Dr. Z

Code 36556 is the correct code to use for a cooling catheter placed in the cath lab during a cardiac cath. When 36556 is used in IR to report CVC placement, the physician must document where the tip of the catheter resides. Does this also hold true for documentation in the cath lab? Most of the time the physicians only state that the ICY/cooling catheter is placed via the femoral vein or in the femoral vein. No documentation of where the tip ends. When documentation is lacking, should this be coded as a midline catheter (36140), or is it still okay to report with 36556? This is for facility coding if that makes a difference.