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2025 CPT code 49421

Open insertion of a tunneled intraperitoneal catheter for dialysis.

Follow current CPT guidelines for surgical procedures.Appropriate modifiers should be applied as needed.

Modifiers may be applicable depending on the circumstances of the procedure (e.g., 59 for distinct procedural service, 78 for unplanned return to the operating room, etc.).

Medical necessity is established by the patient's need for dialysis due to end-stage renal disease or the need for long-term management of recurrent ascites.Documentation should support the clinical indication for the procedure.

The surgeon is responsible for all aspects of the procedure, including patient preparation, anesthesia, incision, catheter placement, tunnel creation, hemostasis, and wound closure.They may also extend the catheter to a remote chest site.

IMPORTANT:For percutaneous insertion with imaging guidance, see 49418. For insertion of a completely implantable tunneled intraperitoneal catheter with a subcutaneous port, see 49419. For laparoscopic insertion, see 49324. For removal, see 49422. For subcutaneous extension of intraperitoneal catheter with remote chest exit site, use 49435 in conjunction with 49421.

In simple words: A surgeon places a tube (catheter) inside the belly to allow for dialysis, a treatment for kidney disease that cleans the blood. The tube is carefully placed and secured under the skin.

This procedure involves the surgical placement of a tunneled intraperitoneal catheter into the peritoneal cavity for the purpose of dialysis.The surgeon makes a midline abdominal incision, identifies a suitable location within the peritoneum, and inserts the catheter. A subcutaneous tunnel is created to bring the catheter's external end to a separate abdominal site. Hemostasis is achieved, and the incision is closed in layers.The procedure may include extending the catheter to a remote chest site.

Example 1: A 60-year-old male with end-stage renal disease requires peritoneal dialysis.The surgeon performs an open insertion of a tunneled intraperitoneal catheter., A 72-year-old female with recurrent ascites undergoes an open insertion of a tunneled intraperitoneal catheter to manage fluid accumulation. The catheter is extended to a remote chest site for optimal drainage., A 45-year-old male with kidney failure and peritoneal dialysis access requires replacement of a malfunctioning tunneled intraperitoneal catheter. The surgeon removes the old catheter and inserts a new one using an open technique.

Preoperative assessment including renal function tests, imaging studies (if any), informed consent, operative report detailing incision site, catheter placement, tunnel creation, and closure technique, and postoperative care instructions.

** This procedure is typically performed under general or regional anesthesia.The specific type of catheter used may vary.

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