Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 36556 and 93312-26-XS billed for date of service 
March 1, 2023. 
 
You asked the Plan to pay for codes 36556 and 93312-26-XS. You say that medical records were provided to 
support the billing of these codes. The Plan denied your request. The Plan says code 36556 is not supported by 
the medical record. The medical records submitted indicate that a central line was placed via subclavian vein. 
However, the records didn't include documentation of the final position of the tip of the central venous device. 
The Plan says it can't verify the validity and accuracy of the billed service. For code 93312-26-XS, this code is 
included in code 00567, so no separate payment can be made. The documents received do not support that the 
procedure or service was distinct or independent from other services performed; therefore, the use of the XS 
modifier is not supported. 
 
Medicare rules say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 36556 is Insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older.  
 
In addition, the rules say that the XS modifier is to be used to indicate that a service is distinct because it was 
performed on a separate organ/structure. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for codes 36556 and 93312-26-XS. Our 
reviewer says that code 36556 is not supported by the medical record.  The reviewer also says that the use of 
the XS modifier to allow for separate payment of code 93312-26-XS is not supported by the medical record. 
Our physician reviewer found in relation to code 36556, per CPT guidelines for insertion of a non-tunneled 
central inserted central venous catheter, "To qualify as a central venous access catheter or device, the tip of the 
catheter/device must terminate in the subclavian, brachiocephalic (innominate or iliac veins, the superior or 
inferior vena cava, or the right atrium".  In this case, the procedure report does not include sufficient 
documentation of termination of catheter.  Therefore, this procedure cannot be verified. In relation to the use of 
the XS modifier for code 93312-26-XS, the reviewer found that the procedure report does not include sufficient documentation to support separate billing.  The procedure report describes a transesophageal echocardiogram 
(TEE) performed by a nurse and interpretation and report performed by the doctor. To bill a TEE separately 
would be to establish conditions such as myocardial ischemia or cardiac valve disorders, the anesthesiologist 
will be utilizing the transesophageal echo for diagnostic purposes. In this case, when the anesthesiologist has 
the additional certification or documented training in residency and is privileged by the hospital to do the 
complete procedure, the anesthesiologist can and should bill separately for the TEE in addition to the 
anesthesia.  This procedure and modifier cannot be verified, as a separate diagnostic procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 36556 and 93312-26-XS have not been met. Therefore, we decided that 
the Plan does not have to pay for codes 36556 and 93312-26-XS billed for date of service March 1, 2023.