PICC Physician Information

While PICC training is certainly not a required part of your training, the popularity of PICCs is making PICC training almost a necessity. PICCs are different from other CVADs and require specific techniques for peripheral access and tips to increase your success. At PICC Excellence, we recommend that you take the Basic PICC Qualification Training class as it is the technique that is most consistent with central line insertion practices. Whether you decide to take an actual class with an instructor or take a self-study class, you will benefit greatly by learning the specifics of this most popular vascular access device.

There are lots of indications when a PICC is the most appropriate CVAD to use. Here are a few of the most common indications:

Short term nutrition PPN or TPN
Chemotherapy lasting less than 1 year
IV Infusions for patient with bleeding disorders no matter the PTT or INR
Patients with less than three veins for more than three days of IVs
Medications known to damage the intima of veins, ie irritants
Patients receiving IV infusions longer than 5 days (Especially when irritating antibiotics or Phenergan are involved) (Give phenergan rectally or IM whenever possible)
More than 3 restarts of IV in 24 hours
Open chest wounds, tracheostomy or radial neck surgery contraindicating chest line placement
Heparin infusions where number of hematomas are more than available veins (Midline).
Complications with peripheral IVs, more than one infiltration, more than one phlebitis indicating that the patient is sensitive to the medication infusion or push meds
Medications when pH or osmolarity indicate irritation will occur with peripheral IV (pH less than 5 greater than 9, osmolarity greater than 500)
Dopamine or Dobutamine PICC ASAP
Immediately place a PICC for burn patients, if area of skin is available.
Immunocompromised patients requiring hospitalization and IVs (be sure to use Chlorhexidine/Chloraprep!)

Computerized Tomography (CT) is a scan that enables 3D visualization of tissue at various angles for a more complete picture. Blood vessels and other soft tissue cannot be seen on conventional x-rays. CT scans enable visualization with greater detail. Catheter patency must be verified by flushing the catheter with a 10cc syringe and sterile saline confirming normal flushing action without resistance. Free-flowing blood return may also be verified prior to procedure, followed by flushing. All contrast must be warmed to body temperature prior to power injection. A chest x-ray or other means of verification of tip placement prior to each CT injection is recommended.

The FDA has issued a reminder to radiologists, radiologic technologists, radiologic nurses, and IV team nurses about the potential for serious patient injury when vascular access devices not designed to tolerate high pressures are used for power injection of CT or MR contrast media. That reminder specifies that prior to initiation of power injection the user should:

Check the labeling of each vascular access device for the maximum pressure and flow rate designation.
Know the pressure limit setting for your power injector and how to adjust it. Understand that if recommended pressure is exceeded, the device may weaken even if no rupture is obvious, and the weakened device could fail when used again.
Ensure that the pressure limit set for the power injector does not exceed the maximum labeled pressure for the vascular access device(s).
Be aware the pressure required for contrast injection depends on many factors including flow rate, contrast viscosity, tube diameter and length, and any obstruction to flow from kinks, curves and compression. Ruptures occur when the injection pressure exceeds the tolerance of the vascular access device such as catheters, ports and extension tubing.

Indications for CT Power Injection
Patient Evaluation of:

Cysts
Tumors /Masses
Aneurysm
Metastases
Pulmonary Emboli

Thrombosis (Clots)
Thrombolytic Strokes
Trauma
Abscesses
Appendicitis

Why do ruptures occur?
The pressure required for contrast injection depends on many factors including flow rate, contrast viscosity, tube diameter and length, and any obstruction to flow (e.g., kinks, curves, compression). To maintain the flow rate required for a CT or MRI study, a power injector may generate high pressures. Ruptures occur when the injection pressure exceeds the tolerance of the vascular access device(s). If you do know the maximum pressure that the vascular access device can withstand, be sure to adjust your power injector so that it doesn't exceed this limit. It is important to understand that if the recommended pressure for a vascular access device is exceeded, the device could be weakened even though no rupture is evident, and the weakened device could fail to operate properly when it is used again.

Reimbursement information for PICCs and Midlines varies from outpatient to inpatient, one geographical area to another and one hospital to another. Reimbursement for PICCs and Midlines is not as easy as a simple dollar figure. With the institution of the Hospital Outpatient Prospective Payment System (HOPPS) implemented April 1, 2001, all previous CPT procedural codes have changed to Ambulatory Procedure Codes (APC). Implemented at this time was a transitional pass-through for devices in an effort to provide Universal coding for all brands and similar procedures. CPT and APC codes can be cross referenced here.

CPT or Q codes can be utilized to bill specific percutaneous insertion of central lines by a nurse, physician or radiologist. When no professional fee (MD or NP) coding is involved, the codes listed below are considered facility fees. These codes are as follows:

36468 - Placement of a catheter in subclavian or other vein, percutaneous, age 5 or under.
36469 - Placement of catheter in subclavian or other vein, percutaneous, over age 5.
36575 - Repair non tunneled CVC
36550 - Catheter Clearance Alteplase per 10mg or per 1mg. (Infusion 37201)
76937 - Ultrasound insertion of a vascular access device with the aid of ultrasound byPhysician or nurse. CPT/HCPCS 76937,( fluoroscopy 76998) agent. Q code overides CPT, not accepted by all carriers.