Central Line Placement Gems

[Winged Scapula]

A lot of people (not necessarily Rads, mind you) don't fully understand the concept of a sterile field. I mean, they get it, but in practice it's never quite done correctly. It's like when I see someone placing a central line, and after they've got the needle into the vein they then proceed to drag the guidewire all over the unsterile bed before inserting it, Seldinger-style.

Hell, it takes most surgery residents a few months of internship before they figure out how to stay sterile!

Oh yeah, I've seen (and done that) too in my younger days.

Its just that I expect if you have achieved the level of attending and are doing "sterile" procedures you really oughta know what you are doing. The intern and medical student are too busy focusing on getting everything in order, not messing up etc and they make stupid mistakes. I expect more from someone who has done the procedure for years.

You don't know how I have to bite my lip when I see that happening.

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[Blade28]

Its just that I expect if you have achieved the level of attending and are doing "sterile" procedures you really oughta know what you are doing.

An IR fellowship is, what, 1-2 years? So they'd have at most 24 months of training in sterile procedures. That's not that long! I mean, G Surg PGY-3s can still sometimes contaminate the field!

(Again, not trying to bash anyone, just pointing out the differences in training.)

 

[Winged Scapula]

An IR fellowship is, what, 1-2 years? So they'd have at most 24 months of training in sterile procedures. That's not that long! I mean, G Surg PGY-3s can still sometimes contaminate the field!

(Again, not trying to bash anyone, just pointing out the differences in training.)

Yeah, but I'm talking about regular ol radiologists without IR training. I just would have thought that ANYONE doing sterile procedures would have been taught to do them correctly.

But this was a common theme (ie, not with just 1 group, or 1 hospital) it makes me believe that either our two specialties are taught totally differently or its just not really well taught elsewhere.

And as for PGY-3s contaminating themselves...it still happens at the attending level. I turned around and bumped into the Mayo which the MA had placed too close to the US machine and instinctively reached out for it, ungloved and unsterile. But at least I'd known what I'd done!

 

[Blade28]

Yeah, but I'm talking about regular ol radiologists without IR training. I just would have thought that ANYONE doing sterile procedures would have been taught to do them correctly.

Ah, well then, for sure they're occasionally going to contaminate themselves (especially early on)! It just doesn't become second nature until you've done hundreds of sterile procedures, in various settings (ER, OR, bedside, etc.).

 

[Winged Scapula]

Ah, well then, for sure they're occasionally going to contaminate themselves (especially early on)! It just doesn't become second nature until you've done hundreds of sterile procedures, in various settings (ER, OR, bedside, etc.).

Oh, you're just so nice...Rads Lover!

 

[Blade28]

Oh, you're just so nice...Rads Lover!

Now what did I do to deserve that kind of insult? Haven't I always been nice to you?

 

[Dr. V]

FW

Thanks for the input.

The thing I didn't realize was that the probe housing wasn't made flush with the actual transducer and can be off a bit.

Truthfully one should check in both planes, but in practice it's not needed for shallow things since the cone hasn't had time to get large (unless of course you run into equipment malfunction such as I did).

 

[Winged Scapula]

You should always check in 2 planes. I've always regretted it when I've missed the target.

 

[SLUser11]

Dropped my first lung a month or so ago.......


I was very unhappily surprised by the experience, especially since I pride myself (accurately or not) on excellent and safe technique.

I've heard from plenty of experienced surgeons that if you've never dropped a lung, then you haven't done enough lines. Still, it sucked....

 

[Blade28]

Dropped my first lung a month or so ago.......


I was very unhappily surprised by the experience, especially since I pride myself (accurately or not) on excellent and safe technique.

I've heard from plenty of experienced surgeons that if you've never dropped a lung, then you haven't done enough lines. Still, it sucked....

Don't sweat it. 1% PTX rate is the accepted value in the literature - and you're right, if you haven't dropped a lung you haven't done enough lines.

Ironically enough, it's not usually the huge patients where you need an extra-long LP-style needle that get the pneumos. It's the thin, barely flinching, "wow that was easy" CVL that somehow tags the lung.

 

[Winged Scapula]

Don't sweat it. 1% PTX rate is the accepted value in the literature - and you're right, if you haven't dropped a lung you haven't done enough lines.

Yep....if you haven't had a complication, you haven't done enough of a procedure, but it still smarts when you do it. I'm sorry.

Ironically enough, it's not usually the huge patients where you need an extra-long LP-style needle that get the pneumos. It's the thin, barely flinching, "wow that was easy" CVL that somehow tags the lung.

Definitely. The only PTxs I've given have been in the thin patients. I figured it was because I was so used to the fat Pennsylvania patients that I had altered my angle somewhat to compensate and went in too far under the clavicle.

 

[Dr. V]

I've done lots of lines and it still tightens my sphincter every single time.

It's not nearly as "simple" a procedure as some would make it out to be.

I agree that if you haven't popped a lung you haven't done enough lines. It will come.

There are many things you can beat in life, but you usually don't beat the odds. Odds say about one in a hundred and if you are lucky enough to get close to a hundred without a PTX then get ready, yours is coming soon LOL.

A friend of mine just suffered that very thing, he got his first one at slightly over 100 on an "easy stick" on a normal sized person that he thought went very well. Funny how it seems as if the "easy sticks" are usually the ones you get your PTX on.

No matter what it's always tough to have a complication, it just plain sucks.

 

[opr8n]

how common are supraclav lines at your institution
ive never done one
done about 100 central lines
i hear residents from other programs talk about them all the time

its like perc trachs in the ICU, heard about them, but no one did them till I asked an older (ie much more experienced) attending to take me through one

 

[Winged Scapula]

how common are supraclav lines at your institution
ive never done one
done about 100 central lines
i hear residents from other programs talk about them all the time

its like perc trachs in the ICU, heard about them, but no one did them till I asked an older (ie much more experienced) attending to take me through one

Supraclav or subclavian?

The former is pretty unusual, although I watched an anesthesia resident do a subclavian from a supraclavicular approach (it worked). IJs are pretty common although where I trained I tended to see it done more by anesthesia than surgery.

I much prefer the subclavians...probably because it was what the Chief who taught me preferred it and most of my surgical colleagues do them as well. Dressings stick on better, less respiratory goo draining onto wound.

As for perc trachs, this was standard of practice for most ICU patients who had favorable anatomy and no reason to go to the OR. I've done much much more perc trachs than traditional open ones.

 

[Dr. V]

how common are supraclav lines at your institution
ive never done one
done about 100 central lines
i hear residents from other programs talk about them all the time

its like perc trachs in the ICU, heard about them, but no one did them till I asked an older (ie much more experienced) attending to take me through one

I have done one supraclavicular stick. It's good to have in your toolbox in a pinch. It's scary as hell poking straight at the lung, but it comes in handy when other sites are not suitable.

Perc trachs, we do those quite a bit, some of the more old school attendings don't do them but as a whole we do them alot in the ICU.

 

[Blade28]

how common are supraclav lines at your institution
ive never done one

I learned to do one by an ER resident, of all people! He claimed it was great for patients during code situations when someone's pounding on the chest and you don't want to be jabbing a needle below the clavicles.

 

[Pir8DeacDoc]

Do you guys place a lot of lines on your floor patients or more on ICU patients? Where I went to medical school it seemed like there were a lot of central lines placed. Here I've noticed that unless you are in the unit and in the process of getting admitted where you get A-lines and central access, there just aren’t that many central lines placed by surgery. We have a PICC team and they place A LOT of lines in our hospital. Is this uncommon?

 

[Winged Scapula]

Do you guys place a lot of lines on your floor patients or more on ICU patients? Where I went to medical school it seemed like there were a lot of central lines placed. Here I've noticed that unless you are in the unit and in the process of getting admitted where you get A-lines and central access, there just aren’t that many central lines placed by surgery. We have a PICC team and they place A LOT of lines in our hospital. Is this uncommon?

Most of my lines during residency were placed at one of the community hospitals I moonlighted at. Either they had horrible nurses who couldn't place peripherals or the patient population sucked (or both). I noticed a substantial decrease in the number of lines placed after they got a PICC team, especially when they started coming in on the weekends as well.

At my mother ship hospital, the majority of lines were on ICU patients although every now and again a floor patient would need one. We did utilize the PICC team but frankly, if we knew that the junior residents needed practice we would defer to surgeon placed central line instead of PICC.

 

[Blade28]

Do you guys place a lot of lines on your floor patients or more on ICU patients? Where I went to medical school it seemed like there were a lot of central lines placed. Here I've noticed that unless you are in the unit and in the process of getting admitted where you get A-lines and central access, there just aren’t that many central lines placed by surgery. We have a PICC team and they place A LOT of lines in our hospital. Is this uncommon?

Depends on the hospital.

At the university hospital, PICC lines are much more common. These take a while to schedule at the county hospital here so CVLs are the norm there.

 

[SLUser11]

Depends on the hospital.

At the university hospital, PICC lines are much more common. These take a while to schedule at the county hospital here so CVLs are the norm there.

Bumping thread for the benefit of our soon-to-be-interns....

....Actually just bumping to point out that our SDN anesthesia colleagues fancy themselves to be superior to us in the placement of central lines, and state firmly that the ultrasound is a crutch for the weak and near-universally unnecessary if you're good.

 

[filter07]

Bumping thread for the benefit of our soon-to-be-interns....

....Actually just bumping to point out that our SDN anesthesia colleagues fancy themselves to be superior to us in the placement of central lines, and state firmly that the ultrasound is a crutch for the weak and near-universally unnecessary if you're good.

I can see how anesthesiologists can be better than most surgeons when it comes to placing lines. Outside of the ICU or trauma bay, most surgical attendings haven't put in a line in years, maybe decades. I can easily see anesthesiologists being better at lines than a surgical oncologist, a colorectal surgeon, a vascular surgeon, a CT surgeon, and so on.

At the resident level, it probably depends on whoever does the most. At my institution, the surgery residents probably do more, and we are probably better in the first few years. Our interns rotate on trauma and place central lines, whereas maybe in a medicine internship or transitional year (for the anesthesiology residents), they might be running pressors through an 18 gauge peripheral in the MICU. So as a second year the surgeons might be better but that's probably temporary. Also I feel that at my institution, the surgery residents were more eager to learn CVL placement compared to anesthesiology residents, but that probably changes year by year and institution by institution.

What I do think though is that if you are going to place lines blindly when several RCT show better results with US, you better be tracking your outcomes and making sure that your blind technique has the same or better outcomes as the published results using US.

 

[JackADeli]

...What I do think though is that if you are going to place lines blindly when several RCT show better results with US, you better be tracking your outcomes and making sure that your blind technique has the same or better outcomes as the published results using US.

I guess the question then becomes.... what outcomes are you tracking? There is clearly a difference in philosophy of what is a procedure related complication. If someone places a central line in a patient, and a carotid stick occurs in the process, there may be morbidity. However, if you hand off the patient after your procedure and have zero follow-up.... it is impossible to declare a morbidity level. also, quite common to not even document an arterial stick.

But, an arterial stick can have occult vascular injuries and it can have occult injuries to other structures. It is reported in the literature that mal-sticks and mal-positions can result in in phrenic & recurrent injuries. Arterial sticks can have intramural hematomas and/or dissections that go unrecognized. As surgeons, we ideally have follow up. even on minor procedures, patients will call us if something seems off. Who does the patient call with a late identified carotid injury? how about hoarse after a month in skilled nursing facility? how about the paralyzed hemidiaphragm recognized 3m, 1yr, 2yr later? I am not saying who is better... I agree with others it is pointless. I am saying being cavalier about risks cause you don't have follow-up beyond a few hours is intellectually dishonest.

 

[SLUser11]

Bumping thread for the benefit of our soon-to-be-interns....

....Actually just bumping to point out that our SDN anesthesia colleagues fancy themselves to be superior to us in the placement of central lines, and state firmly that the ultrasound is a crutch for the weak and near-universally unnecessary if you're good.

I had an interesting one today, not a Plankton virgin chip shot neck, but a dialysis patient with chronic access problems who had no venous access (therefore no sedation), and needed emergent IV Abx, blood transfusion, and hemodialysis.

She had an occluded right IJ, stenotic left IJ, central venous stenosis in the brachiocephalic trunk, poor body habitus, multiple failed AV fistulas, multiple failed attempts at CVL and dialysis catheter within the last few days...fresh needle sticks on both sides of neck and both groins...pulled out her femoral line, and they consulted us to save the day......

How many of us have had multiple patients like this over the years? The reason I trust the general surgeon to place the central line is because we are accustomed to placing difficult lines, in nightmare patients. Now there are plenty of anesthesia docs with excellent line skills, but five layup right IJs a week can't prepare you for that....

Anyway, despite my obviously inadequate technique, I was able to place a tunneled left IJ DLDC using the glidewire, venogram, and gentle central venous dilation. I then placed a right subclavian CVL on first stick. No sedation, poorly working bed in the ICU, and minimal nursing assistance.

I used ultrasound and fluoro because apparently I'm weak.....

I'm not saying that as a specialty we are better, but we're definitely not worse.

 

[filter07]

Should the DLDC not be used for things other than dialysis? I ask because you put in a separate subclavian CVL.

 

[SLUser11]

Should the DLDC not be used for things other than dialysis? I ask because you put in a separate subclavian CVL.

We pack our dual lumen dialysis catheters with concentrated heparin.

1. Most floor nurses don't have the privileges (or the desire, or the knowledge) to draw the heparin out prior to administration of medications, then replace it.

2. Accidental flushing of said heparin can lead to life-threatening coagulopathies. Failure to replace said heparin will lead to frequent line clotting and replacement procedures.

3. Patients in extremis, like this one, frequently need simultaneous hemodialysis and admin of other meds and fluids, not all of which are compatible or practical with our dialysis machines.

I'm not sure what the national standard is, but in the places that I've practiced, dialysis catheters are off limits to ward and ICU nurses. They are used like a regular CVL only in emergencies.

I can see how anesthesiologists can be better than most surgeons when it comes to placing lines. Outside of the ICU or trauma bay, most surgical attendings haven't put in a line in years, maybe decades.

Not true. Most general surgeons in private practice place central lines all the time. They are doing portacaths, hickmans, and dialysis catheters (which all pay well, btw). They also can get consults for CVLs in community hospitals.

 

[SouthernSurgeon]

I'm not sure what the national standard is, but in the places that I've practiced, dialysis catheters are off limits to ward and ICU nurses. They are used like a regular CVL only in emergencies.

That was my experience in med school as well. We also had more than one savvy dialysis patient who knew better than to let a floor nurse touch their catheter.

 

[SLUser11]

Dude, are you serious?

Anesthesiologists only do a handful of procedures...

Epidurals, spinals, nerve blocks, intubations, and lines. That's about it.

We learn those few procedures very well.

IV access is everything to us, needed for our job, and we are forced to become very good at it. If the patient is going to the OR and there is no peripheral IV access, guess what we do next? In private practice we do a ton of central lines. The patients are rarely chip shots, otherwise we would be doing peripheral IVs in them.

Surgeons have much bigger things to worry about, procedure-wise.

I was a former surgery resident, by the way.

I'm not here to get into a long heated argument, you can have the last word if you want it.

Don't get me wrong, I'm not trying to own the procedure. There are excellent anesthesia proceduralists all over the country. I just think it's absurd for Plank to claim that anesthesiologists are inherently better at CVLs, especially when my personal experience is the complete opposite of that. I've been called into the OR many times by anesthesia to place a line after they failed to get one in.

My opinion is that there are line experts out there from several specialties, and their ability to troubleshoot is based on personal experience. Plank made it sound like doing elective IJs for heart cases made him god's gift to the CVL. I just wanted to give an example of some of the line disasters that we deal with every day.

That being said, I want the other thread to die so badly that I'm not responding to any of his posts. I posted my nightmare line experience here in our own central line thread as a cathartic second option.

And I agree...a long heated (and biased) debate from both of us solves nothing. That's the main reason I stepped out of the other discussion.

 

[filter07]

We pack our dual lumen dialysis catheters with concentrated heparin.

1. Most floor nurses don't have the privileges (or the desire, or the knowledge) to draw the heparin out prior to administration of medications, then replace it.

2. Accidental flushing of said heparin can lead to life-threatening coagulopathies. Failure to replace said heparin will lead to frequent line clotting and replacement procedures.

3. Patients in extremis, like this one, frequently need simultaneous hemodialysis and admin of other meds and fluids, not all of which are compatible or practical with our dialysis machines.

I'm not sure what the national standard is, but in the places that I've practiced, dialysis catheters are off limits to ward and ICU nurses. They are used like a regular CVL only in emergencies.

Thank you, that was a pretty good explanation.

Not true. Most general surgeons in private practice place central lines all the time. They are doing portacaths, hickmans, and dialysis catheters (which all pay well, btw). They also can get consults for CVLs in community hospitals.

Once again my academic bias got the better of me. Old habits die hard..

 

[CME2P]

Wow, I consider myself a pro at lines, and I learned a few tricks on here. About the U/S: if you have one available in your hospital, use it, especially in high risk pts.

On our transplant service we routinely have emergent lines in uremic pts, inr's in double digits, and plt counts less than 10. Those are pt that you absolutely want an IJ under U/S. I have found that after learning to use it, it only takes about an extra 60-90 seconds. The last thing you want is to be standing in front of a crowd showing a PPT and explaining why the pt with a BUN of 100, PLT 10, INR 11 had their carotid inadvertantly dilated without sonographic guidance.

 

[Winged Scapula]

Not true. Most general surgeons in private practice place central lines all the time. They are doing portacaths, hickmans, and dialysis catheters (which all pay well, btw). They also can get consults for CVLs in community hospitals.

I've not found that to be the case.

A tunneled catheter with port pays around $300-350 (depending on state, insurance); removing them pays only a little less.

While they don't take long to do, there are other things you can do for more money in the same amount of time.

 

[SLUser11]

I've not found that to be the case.

A tunneled catheter with port pays around $300-350 (depending on state, insurance); removing them pays only a little less.

While they don't take long to do, there are other things you can do for more money in the same amount of time.

Here, even medicare reimbursement is better than that. For a portacath, it can pay $800-1000. Dialysis catheters pay about $375-400, and removal of catheters about $300. To me, that's pretty good money considering what a hernia or gallbladder pays, especially since lines take about 10-15 minutes, and line removals take even less time....

The sad part is that the medicare reimbursement for colonoscopies that I've seen is down around $110-150, so I've joked that I plan on a being a colorectal surgeon/dialysis catheter expert.

 

[Winged Scapula]

Here, even medicare reimbursement is better than that. For a portacath, it can pay $800-1000. Dialysis catheters pay about $375-400, and removal of catheters about $300. To me, that's pretty good money considering what a hernia or gallbladder pays, especially since lines take about 10-15 minutes, and line removals take even less time....

Are you sure?

When I use the AMA CPT search for Medicare reimbursement rates for code 36561 (tunneled line with subcut port) for Wichita I get $319.72. This is about what I get paid here for them; about $50 less for removing them.

Hell, if it were $1000 then I agree its worth it but I don't seen any evidence that's what insurances are paying (I have an Excel spreadsheet with rates from all my insurers and NONE are paying more than $400). Are they billing for fluoro time and eval as well? That would bump it up, but I can't imagine it would double the reimbursement (knowing what imaging eval for these things pays).

If your attendings are doing something different (ie, placing them in an office setting, then the non-facility reimbursement IS around $900), let me know. And you're right - they don't take long, but then you have set-up, room clean time, and next thing you know, its been an hour (OR MORE); since a lap chole can be done in 20 mins in many patients, makes sense to do higher reimbursing things.

 

[SLUser11]

Are you sure?

When I use the AMA CPT search for Medicare reimbursement rates for code 36558 (tunneled line with subcut port) for Wichita I get $319.72. This is about what I get paid here for them; about $50 less for removing them.

Hell, if it were $1000 then I agree its worth it but I don't seen any evidence that's what insurances are paying (I have an Excel spreadsheet with rates from all my insurers and NONE are paying more than $400). Are they billing for fluoro time and eval as well? That would bump it up, but I can't imagine it would double the reimbursement (knowing what imaging eval for these things pays).

I'm not sure, I'll have to re-check to get an exact number. I've been told that fluoro definitely bumps up reimbursement for portacaths. As for medicare, it's possible I was looking at an outdated spreadsheet. I do remember that for portacaths, there was a big difference between private and medicare reimbursements.

Another thing is that big groups, like the one here in Wichita, have more bargaining power when determining private insurance reimbursement, which may play a role.

If I can find the actual info I'll pm it to you.

 

[jdh71]

IM guy here . . . where I train the U/S is a requirement for every line, even femorals, unless the line was placed during a code. But we do put in our own lines. To me it just makes sense to use the U/S. I mean why would't I use it if given the option to use it? To me it's like shooting a rifle with metal sights vs using a scope - sure you can get good shooting with metal sights, but you can see so much better with a scope.

Some of the resistance seems more to do with "machismo" than any sort of rational argument - emergent situations notwithstanding.

 

[Winged Scapula]

I'm not sure, I'll have to re-check to get an exact number. I've been told that fluoro definitely bumps up reimbursement for portacaths. As for medicare, it's possible I was looking at an outdated spreadsheet. I do remember that for portacaths, there was a big difference between private and medicare reimbursements.

Another thing is that big groups, like the one here in Wichita, have more bargaining power when determining private insurance reimbursement, which may play a role.

If I can find the actual info I'll pm it to you.

Image guidance does definitely bump up reimbursment and you're right, larger groups have more bargaining power than us little guys (although we've done some bargaining by simply being the only fellowship trained breast surgeons in the valley). It depends on what they're contracted for - if they are being paid 150% of CMS rates plus the image component, then I could see it approaching the $900 range (although 150% CMS is pretty wildly high).

You can always look up CMS current rates on the AMA website.

But do let me know because I know the med oncs like it if the surgeons put in the lines rather than rads (and the patients seem to prefer it as well...something about more sedation/anesthesia, less flipping of ports due to being sutured in).

 

[SLUser11]

Image guidance does definitely bump up reimbursment and you're right, larger groups have more bargaining power than us little guys (although we've done some bargaining by simply being the only fellowship trained breast surgeons in the valley). It depends on what they're contracted for - if they are being paid 150% of CMS rates plus the image component, then I could see it approaching the $900 range (although 150% CMS is pretty wildly high).

You can always look up CMS current rates on the AMA website.

But do let me know because I know the med oncs like it if the surgeons put in the lines rather than rads (and the patients seem to prefer it as well...something about more sedation/anesthesia, less flipping of ports due to being sutured in).

Awesome link. Thanks for that. When I type in 36561 for that link in Kansas, I get:


Medicare Payment***

36561. Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older $994.01

That's for a "non-facility." For "facility," it says $319, so I'm pretty sure the fluoro guidance is the key to getting up around $1,000.


In practice, I'm planning on doing all my own portacaths, likely with fluoro so I can confirm placement intra-op before closing the skin. As for whether or not I'm going to suture them in, that's a whole other discussion....but I'll say that it depends on the port.

Edit: Now I'm seeing that fluoro only adds $80 to the total, so I'm going to have to phone a friend on this one. I'll let you know what I find out.

 

[SocialistMD]

36561. Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older $994.01

That's for a "non-facility." For "facility," it says $319, so I'm pretty sure the fluoro guidance is the key to getting up around $1,000.

What a crock of ****! Doing the same procedure in a kid < 5 years old (36560) bills $338.09, and in an adult (36561) bills $344.73 (both facility, as that is where I'd be doing them). How can an easier version of the same procedure bill $6 more?!?!?![/sarcastic rant]

At least we make more in St. Louis than you do in Wichita...

 

[Winged Scapula]

The *key* is doing these in a non-facility like your office.

I wonder if those who told you that the reimbursement was around $1000 are billing inappropriately or doing it outside the hospital or ASC (ie, a non-facility). If you have a little procedure room in your office and do it there you can bill the higher rate (without image guidance unless you also have fluoro). They used to have a non-facility rate for mastectomy...I was thinking, "who does those outside a facility?"

Please do let me know and verify that they have checked their EOBs and that's what they're exactly getting (its one thing to bill $1000 [which I do as well since thats about 2.5 times CMS rates] and getting that much).

We get more here too:

CodeDescription **36561. Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older NON FACILITY $1070.76 FACILITY $339.36

 

[Winged Scapula]

What a crock of ****! Doing the same procedure in a kid < 5 years old (36560) bills $338.09, and in an adult (36561) bills $344.73 (both facility, as that is where I'd be doing them). How can an easier version of the same procedure bill $6 more?!?!?![/sarcastic rant]

Ahhh....welcome to the wonderful non-sensical world of billing and reimbursement.

 

[SLUser11]

Ahhh....welcome to the wonderful non-sensical world of billing and reimbursement.

I spoke with one of my bosses, and he agreed that the medicare reimbursement was low, in the range of $350-400 with fluoro, and his high reimbursements were all from private insurance companies. I believe the vast majority of these are done in a "facility" here in Wichita.

Although I would add that $400 isn't chump change, and is more than we get for lots of other procedures. Also, many of these people have private insurance in certain practice environments. I have to say that I'm still planning on doing them.

 

[notinkansas]

Where I did my 3 years of gen surg residency, the anesthesia residents were often better at lines. They had more practice, putting them in a lot in the OR.

The gen surg residents had total of 4 only months ICU time. Institutional culture is that even thinking about putting a central line in a floor pt is heresy (unless pt in extremis.) PICC team covers central access on floor and many ICU pts. If a PICC won't cut it for ICU pts the lines often placed my midlevel, as resident is deemed more necessary for rounds, is post call, has to go to conference or has some other activity. End result: many gen surg residents aren't completely comfortable with lines.

In my current moonlighting type job, sometimes I'm called to MICU to help with a line. I've noticed my skill seems to be deteriorating. It also seems that more often pts are super obese- sometimes I wonder if the needle is long enough! Plus I didn't have the benefit of being trained with US. I feel at a disadvantage when faced with a 400+ lb pt.

 

[notinkansas]

What a crock of ****! Doing the same procedure in a kid < 5 years old (36560) bills $338.09, and in an adult (36561) bills $344.73 (both facility, as that is where I'd be doing them). How can an easier version of the same procedure bill $6 more?!?!?![/sarcastic rant]

Same way a mediport pays more than a mastectomy. Finding out this kind of BS was one of the many factors that made me think "WTF have I done by going into medicine?"

Don't even get me started on what would happen if you tried to tell your plumber, "I will only reimburse you X for doing this procedure, and if you don't submit a bill that meets all these criteria I won't pay you at all"

 

[Winged Scapula]

I spoke with one of my bosses, and he agreed that the medicare reimbursement was low, in the range of $350-400 with fluoro, and his high reimbursements were all from private insurance companies. I believe the vast majority of these are done in a "facility" here in Wichita.

Although I would add that $400 isn't chump change, and is more than we get for lots of other procedures. Also, many of these people have private insurance in certain practice environments. I have to say that I'm still planning on doing them.

I get that these are private insurers which is why I can't figure out the reimbursement.

My Medicare population is only about 11%; I do have to see some of the Arizona Medicaid (AHCCCS) patients if I accept private insurance - these plans typically only pay 90-100% of CMS rates. The rest are privates with a very small smattering of self-pays.

What I'd like to know is what percentage of Medicare rates are your bosses contracted for? Because most people I've met say they get between 100 and 130% of CMS rates...so even for a $320 CMS rate line, private insurers are only paying around $400 here.

Unless I am doing something wrong or they have substantially better contracts - like 300% of CMS (which could be the case).

You're right $400 isn't chump change but for things I do, it ranks pretty high in terms of risk to patient, so not worth it to me.

 

[Dr.LeoSpaceman]

What's the longest you guys have spent trying to place an internal jugular CVC? Recently had a patient who was extremely obese, massive neck, IJ was on the deeper side about 2.5 cm, and completely collapsed with respirations. He was also awake and had difficulty staying still. Admitting service specifically asked for IJ or subclavian. Took me an hour to place it. I spent about 30 min trying, attending was walking by and noticed, they then tried but couldn't get it, and finally I got it. Decided to go through the vessel and retract. I don't generally like doing that technique and my needle was in pretty deep already.

Unless there is a medical reason they needed a IJ/subclavian, I'd have put a femoral in and then let IR try after a few passes from a trainee then attending. Particularly of the patient is awake. As a trainee, spending 30 minutes trying to access a tough IJ seems neither safe or efficient.

 

[ThoracicGuy]

Unless there is a medical reason they needed a IJ/subclavian, I'd have put a femoral in and then let IR try after a few passes from a trainee then attending. Particularly of the patient is awake. As a trainee, spending 30 minutes trying to access a tough IJ seems neither safe or efficient.

Only caveat to this is if they are really obese, the femoral line may not be so easy either.

 

[Jolie South]

Only caveat to this is if they are really obese, the femoral line may not be so easy either.

Yes like the ones where you have to smash the sub cutaneous fat with the ultrasound and can’t let up with the probe until someone else feeds your wire.

I did bilateral venous access for iliac stents like this recently.

 

[ThoracicGuy]

Yes like the ones where you have to smash the sub cutaneous fat with the ultrasound and can’t let up with the probe until someone else feeds your wire.

I did bilateral venous access for iliac stents like this recently.

And don't forget the assistant holding the pannus out of the way...

 

[LucidSplash]

And don't forget the assistant holding the pannus out of the way...

If in the OR, that assist is called “3-inch silk tape.”

 

[ThoracicGuy]

If in the OR, that assist is called “3-inch silk tape.”

With or without mastisol?

 

[Medstart108]

What's the longest you guys have spent trying to place an internal jugular CVC? Recently had a patient who was extremely obese, massive neck, IJ was on the deeper side about 2.5 cm, and completely collapsed with respirations. He was also awake and had difficulty staying still. Admitting service specifically asked for IJ or subclavian. Took me an hour to place it. I spent about 30 min trying, attending was walking by and noticed, they then tried but couldn't get it, and finally I got it. Decided to go through the vessel and retract. I don't generally like doing that technique and my needle was in pretty deep already.

Probably 10 minutes. Never had a situation as tough as yours though, most of my central lines have been supervised so if I didn't get it in 10 they took over, the ones I've done unsupervised were gimmies and u/s guided. I find the most important thing about central lines is not shoving anything in farther than it needs to go. I've seen a IJ vascath go in and out the IJ and into the subclavian artery and down to the ascending aorta apparently "u/s guided". Patient needed cardiac surgery to repair it and apparently was fully anticoagulated and bled 3L in the OR.