2025 CPT code 36010
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Cardiovascular System Surgery Feed
Introduction of catheter into superior or inferior vena cava.
Modifiers may apply depending on the circumstances, such as multiple procedures (modifier 51), bilateral procedures (modifier 50), or other modifiers as per CPT guidelines.
Medical necessity is established by the clinical indication for the procedure, such as the diagnosis and management of DVT, administration of medication requiring central venous access, or other cardiac interventions.Appropriate documentation is required to support the medical necessity of the procedure.
The physician is responsible for patient preparation, local anesthesia administration (or overseeing general anesthesia), incision, catheter insertion and navigation, contrast or medication administration, and any additional procedures performed. Post-procedure care specifically related to the injection procedure is included.The physician may also interpret the resulting images.
In simple words: The doctor inserts a thin tube (catheter) into a large vein in your body (either the superior or inferior vena cava) to give medicine or do another procedure, like taking X-ray images of your veins or opening a blocked vein.
This CPT code encompasses the introduction of a catheter into the superior or inferior vena cava.The procedure may involve the administration of medication, contrast material, or other substances. It may also include additional procedures such as angiography, venography, or angioplasty.The procedure necessitates local anesthesia, incision for catheter access (typically in the groin), and catheter navigation through the vessels to reach the vena cava. Pre- and post-injection care specific to the injection is included.
Example 1: A patient presents with suspected deep vein thrombosis (DVT).A venogram is performed using catheterization of the inferior vena cava via the femoral vein to visualize blood flow and identify any clots., A patient requires medication administration directly into the superior vena cava.A central venous catheter is placed, and the medication is infused., A patient undergoes cardiac catheterization.The procedure includes the insertion of a catheter into the inferior vena cava to access the heart chambers for angiographic imaging or intervention.
Detailed medical history, physical examination findings, informed consent documentation, images from any radiological studies (e.g., fluoroscopy, X-ray), complete procedural notes documenting the approach, catheter placement, medications or contrast administered, and any complications encountered. If a secondary procedure was done, detailed documentation for that procedure is also required. Post-procedure monitoring and findings must also be documented.
** The description of the procedure should clearly specify the approach used (e.g., femoral vein access), the location of the catheter placement (superior or inferior vena cava), and any additional procedures performed.Always refer to the most current version of the CPT manual for coding guidelines and any updates to the code.
- Revenue Code: I4B (IMAGING/PROCEDURE - OTHER)
- RVU: This information is not available in the provided source.Refer to the AMA CPT codebook or other relevant reimbursement guidelines for RVU values. RVUs vary based on geographic location and other factors.
- Global Days: Information on global surgical days is not available in the provided source.The global period would depend on the specific procedure performed in conjunction with the catheterization.
- Payment Status: Active
- Modifier TC rule: The application of a Technical Component (TC) modifier will depend on the specific services performed and the nature of the involvement of different healthcare providers.Refer to the CPT manual for guidance.
- Fee Schedule: Historical fee schedule information is unavailable in the provided source. Fee schedules are subject to change and vary by payer and location.
- Specialties:Cardiology, Interventional Radiology, Vascular Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center