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Official Description

Introduction of catheter, superior or inferior vena cava

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 36010 refers to the procedure of introducing a catheter into the superior or inferior vena cava, which are major veins in the body responsible for returning deoxygenated blood to the heart. This procedure is commonly performed through access veins such as the brachial and cephalic veins. During the procedure, a small incision is made at the planned puncture site to facilitate access to the vein. An introducer sheath is then placed within the vein to allow for the safe passage of instruments. Following this, a guidewire is carefully advanced through the access vein and directed into either the superior or inferior vena cava. If the access point is through the brachial or cephalic vein, the guidewire and catheter are maneuvered through the superior vena cava, passing through the right atrium before reaching the inferior vena cava. This technique is essential for various medical interventions, including the administration of medications or radiopaque contrast agents, which may be injected as necessary during the procedure to enhance imaging or therapeutic effects.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure described by CPT® Code 36010 is indicated for various clinical scenarios where access to the superior or inferior vena cava is necessary. The following conditions may warrant this procedure:

  • Access for Central Venous Catheterization This procedure is often performed to establish access for central venous catheterization, which is crucial for administering medications, fluids, or blood products.
  • Hemodynamic Monitoring It may be indicated for hemodynamic monitoring, allowing for the assessment of cardiovascular function and fluid status in critically ill patients.
  • Administration of Chemotherapy The procedure is also indicated for the administration of chemotherapy agents, which may require central venous access for effective delivery.
  • Long-term Venous Access Patients requiring long-term venous access for chronic conditions may also benefit from this procedure, facilitating ongoing treatment without repeated venipuncture.

2. Procedure

The procedure for CPT® Code 36010 involves several critical steps to ensure successful catheter placement into the superior or inferior vena cava. The following procedural steps are outlined:

  • Step 1: Preparation and Anesthesia The patient is positioned appropriately, and the area over the planned puncture site is cleaned and sterilized. Local anesthesia may be administered to minimize discomfort during the procedure.
  • Step 2: Incision and Introducer Sheath Placement A small incision is made at the puncture site, typically over the brachial or cephalic vein. An introducer sheath is then inserted into the vein to provide a pathway for the guidewire and catheter.
  • Step 3: Guidewire Advancement A guidewire is carefully advanced through the introducer sheath and into the access vein. The clinician navigates the guidewire towards the superior or inferior vena cava, ensuring proper placement.
  • Step 4: Catheter Insertion Once the guidewire is in place, a catheter is advanced over the guidewire into the superior or inferior vena cava. If the access is through the brachial or cephalic vein, the guidewire and catheter are maneuvered through the superior vena cava and right atrium to reach the inferior vena cava.
  • Step 5: Injection of Contrast or Medication As needed, the clinician may inject medication or radiopaque contrast through the catheter to facilitate imaging or therapeutic interventions.

3. Post-Procedure

After the completion of the catheter introduction procedure, the patient is monitored for any immediate complications or adverse reactions. The insertion site is typically bandaged, and instructions for care are provided to the patient. Follow-up imaging may be required to confirm the proper placement of the catheter within the superior or inferior vena cava. Patients may also receive guidance on signs of infection or other complications to watch for during the recovery period. Regular assessments and maintenance of the catheter site are essential to ensure continued function and prevent complications.

Short Descr PLACE CATHETER IN VEIN
Medium Descr INTRO CATHETER SUPERIOR/INFERIOR VENA CAVA
Long Descr Introduction of catheter, superior or inferior vena cava
Status Code Active Code
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 1 - 150% payment adjustment for bilateral procedures applies.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
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) I4B - Imaging/procedure - other
MUE 2
CCS Clinical Classification 54 - Other vascular catheterization, not heart

This is a primary code that can be used with these additional add-on codes.

37252 Addon Code MPFS Status: Active Code APC N ASC N1 Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; initial noncoronary vessel (List separately in addition to code for primary procedure)
37253 Addon Code MPFS Status: Active Code APC N ASC N1 Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure)
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).
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.
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).
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
AO Alternate payment method declined by provider of service
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.)
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.
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).
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).
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.
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.
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.)
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
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).
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CR Catastrophe/disaster related
ET Emergency services
GC This service has been performed in part by a resident under the direction of a teaching physician
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
KX Requirements specified in the medical policy have been met
PD Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
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
SG Ambulatory surgical center (asc) facility service
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
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
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2017-01-01 Changed Moderate (Conscious) Sedation flag removed. See new Moderate Sedation category.
2013-01-01 Changed Added Conscious Sedation Icon
Pre-1990 Added Code added.
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