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Official Description

Introduction of needle or intracatheter, vein

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 36000 involves the introduction of a needle or intracatheter into a vein. This is a fundamental technique used in various medical settings, primarily for the purpose of accessing the venous system for diagnostic or therapeutic interventions. The physician may utilize different types of devices for this procedure, including a metal needle, commonly known as a butterfly or scalp needle, or a plastic catheter that is mounted on a metal needle, often referred to as a plastic needle. Additionally, an intracatheter, which is a catheter that is inserted through a needle, may also be employed. The process begins with the careful selection and cleansing of the planned puncture site to minimize the risk of infection. Once the site is prepared, the selected device is introduced into the vein. The butterfly needle is particularly useful for accessing smaller veins, such as those found in the hand, due to its design that stabilizes the hub on the skin surface. In the case of a plastic needle, the metal tip is first inserted into the vein, after which it is removed, allowing the plastic catheter to be advanced into the vein. If an intracatheter is utilized, the metal needle punctures the vein, and the catheter is subsequently introduced through the needle into the vein. To ensure stability and prevent movement, the needle or intracatheter is secured to the skin with tape, completing the procedure.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure associated with CPT® Code 36000 is indicated for various clinical scenarios where venous access is required. The following conditions may warrant the use of this procedure:

  • Venous Access for Medication Administration This procedure is often performed to establish venous access for the administration of medications, fluids, or blood products.
  • Diagnostic Testing It may be indicated for obtaining blood samples for laboratory testing, allowing for the assessment of various health conditions.
  • Intravenous Therapy The procedure is utilized to initiate intravenous therapy, which may include hydration, electrolyte replacement, or other therapeutic interventions.
  • Emergency Situations In emergency settings, rapid venous access is critical for the administration of life-saving treatments.

2. Procedure

The procedure for CPT® Code 36000 involves several key steps that ensure safe and effective venous access. The following outlines the procedural steps:

  • Step 1: Site Selection and Cleansing The physician begins by selecting an appropriate puncture site, typically a vein that is easily accessible. The selected site is then thoroughly cleansed using an antiseptic solution to reduce the risk of infection.
  • Step 2: Device Introduction After the site is prepared, the physician introduces the selected device into the vein. If a butterfly needle is used, it is carefully inserted into the vein, with the butterfly shape providing stability on the skin surface. For a plastic needle, the metal tip is first inserted into the vein, and then the metal needle is removed, allowing the plastic catheter to be advanced into the vein.
  • Step 3: Intracatheter Insertion In cases where an intracatheter is utilized, the metal needle punctures the vein, and the catheter is then introduced through the needle into the vein. This method allows for secure access to the venous system.
  • Step 4: Securing the Device Once the needle or intracatheter is in place, it is secured to the skin with tape to prevent movement and ensure stability during the procedure and subsequent treatment.

3. Post-Procedure

After the completion of the procedure, the patient may be monitored for any immediate complications, such as bleeding or discomfort at the puncture site. It is essential to ensure that the venous access remains patent and that the device is functioning correctly. The healthcare provider may provide instructions regarding care for the puncture site, including keeping it clean and dry, and monitoring for signs of infection or other complications. Follow-up assessments may be necessary to evaluate the effectiveness of the venous access and to determine if further interventions are required.

Short Descr PLACE NEEDLE IN VEIN
Medium Descr INTRODUCTION NEEDLE/INTRACATHETER VEIN
Long Descr Introduction of needle or intracatheter, vein
Status Code Bundled Code
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 9 - Not Applicable
Multiple Procedures (51) 9 - Concept does not apply.
Bilateral Surgery (50) 9 - Concept does not apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 9 - Concept does not apply.
Co-Surgeons (62) 9 - Concept does not apply.
Team Surgery (66) 9 - Concept does not apply.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Items and Services Packaged into APC Rates
ASC Payment Indicator Packaged service/item; no separate payment made.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) I1F - Standard imaging - other
MUE 4
CCS Clinical Classification 54 - Other vascular catheterization, not heart
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
GC This service has been performed in part by a resident under the direction of a teaching physician
GY Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
JW Drug amount discarded/not administered to any patient
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
LT Left side (used to identify procedures performed on the left side of the body)
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
CR Catastrophe/disaster related
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
RT Right side (used to identify procedures performed on the right side of the body)
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
X5 Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
26 Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
50 Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
53 Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
56 Preoperative management only: when 1 physician or other qualified health care professional performed the preoperative care and evaluation and another performed the surgical procedure, the preoperative component may be identified by adding modifier 56 to the usual procedure number.
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
73 Discontinued out-patient hospital/ambulatory surgery center (asc) procedure prior to the administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient's surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general). under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of modifier 73. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
77 Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
82 Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
99 Multiple modifiers: under certain circumstances 2 or more modifiers may be necessary to completely delineate a service. in such situations modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service.
AG Primary physician
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CS Cost-sharing waived for specified covid-19 testing-related services that result in and order for or administration of a covid-19 test and/or used for cost-sharing waived preventive services furnished via telehealth in rural health clinics and federally qualified health centers during the covid-19 public health emergency
FS Split (or shared) evaluation and management visit
GW Service not related to the hospice patient's terminal condition
GZ Item or service expected to be denied as not reasonable and necessary
JA Administered intravenously
PO Excepted service provided at an off-campus, outpatient, provider-based department of a hospital
PT Colorectal cancer screening test; converted to diagnostic test or other procedure
Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
Q3 Live kidney donor surgery and related services
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
SA Nurse practitioner rendering service in collaboration with a physician
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
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