Intraosseous Access

CPT 36680
Approach Bedside
Preoperative Diagnosis:

Emergency vascular access required: [cardiac arrest / hemorrhagic shock / failed peripheral IV access / emergent medication administration]

Postoperative Diagnosis:

Same

Procedure Performed:

Intraosseous access placement, [proximal tibia / distal tibia / humeral head / sternum]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Nurse/tech name]

Anesthesia:

None [emergent placement] / [local: 2% lidocaine 2 mL IO for conscious patients prior to use]

Indications:

The patient is a [age]-year-old [male/female] in [cardiac arrest / decompensated shock / pulseless state] requiring emergent vascular access. [X] attempts at peripheral IV access were unsuccessful [or peripheral access was not feasible given time constraints]. Intraosseous access was established for emergent medication and fluid administration. The urgency of the procedure precluded obtaining formal consent; [family was notified / procedure performed under emergency exception].

Findings:

The [proximal tibia / humeral head] was accessible. The IO needle was advanced using the [EZ-IO / FAST1 / manual] device. Correct marrow cavity position was confirmed by [aspiration of bone marrow / ability to flush without resistance or subcutaneous extravasation]. Medications and fluids were administered successfully through the IO.

Description of Procedure:

Given the emergent clinical situation, IO access was established without delay. The [right / left] [proximal tibia / proximal humerus / distal tibia] was selected as the access site.

[Proximal tibia technique:] The patient's leg was positioned with the knee slightly flexed. The tibial tuberosity was identified by palpation. The insertion site was identified [2 cm medial and 2 cm distal to the tibial tuberosity] on the flat anteromedial surface. The site was [prepped with ChloraPrep / not prepped given emergent circumstances].

A [15 mm / 25 mm / 45 mm] EZ-IO needle was inserted perpendicular to the bone with a [clockwise / power drill] motion until a decrease in resistance was felt upon entering the marrow cavity. The needle was confirmed stable (will not rotate or fall when released). The stylet was removed. Aspiration of bone marrow confirmed marrow cavity position. The IO was flushed with [10] mL of normal saline. Infusion without resistance or extravasation confirmed correct placement.

[For conscious patients: 2 mL of 2% preservative-free lidocaine was infused slowly IO prior to fluid administration to reduce pain.] The IO was connected to the infusion line with a Luer-lock extension set. Fluids and medications were administered through the IO.

The IO was secured and the extremity was labeled prominently. The IO was used until conventional vascular access was established [X] minutes later.

Complications:

None

Specimens:

[Bone marrow aspirate sent for laboratory studies if peripheral blood not available: CBC, BMP, type and screen / None]

Estimated Blood Loss:

None

Drains:

None. IO needle removed after conventional vascular access established at [time].

Disposition:

IO access functioned appropriately throughout resuscitation. The IO was removed after peripheral [or central] venous access was established. The insertion site was inspected. No extravasation, compartment syndrome, or osteomyelitis signs were noted.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Emergency vascular access: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Intraosseous access, ***
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: None (emergent) / IO lidocaine for conscious patient

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX in *** requiring emergent IO access. *** failed IV attempts. Procedure performed under emergency exception.

FINDINGS: *** IO placed via *** device. Marrow confirmed by aspiration and flush without extravasation. Medications/fluids administered successfully.

PROCEDURE:
*** selected as IO site. *** identified by palpation. Site prepped ***. *** mm EZ-IO needle inserted perpendicular to bone. Loss of resistance on entering marrow cavity. Needle stable on release. Marrow aspirated. Flushed with 10 mL NS. No extravasation. IO lidocaine ***. Connected to infusion line. Labeled. Used until *** access established at ***.

COMPLICATIONS: None
DISPOSITION: IO removed after conventional access established. Site inspected. No extravasation or compartment syndrome.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Humeral Head Approach

The humeral head approach was used given [leg injuries / bilateral lower extremity fractures / prior tibial IO attempts]. The patient's arm was adducted and internally rotated. The greater tubercle of the humerus was identified 2 cm above the surgical neck. A 25 mm EZ-IO needle was inserted at a 45-degree angle directed toward the elbow. Marrow aspiration and resistance-free flush confirmed correct position. Note: flow rates are similar to tibial IO but may be slightly slower.

Pediatric IO (Manual Needle)

In the pediatric patient ([age] years, [weight] kg), IO access was established using a [Cook / Jamshidi] manual IO needle. The proximal tibia was accessed [2 cm below the tibial tuberosity] perpendicular to the bone. A rotary motion was used to advance the needle. The stylet was removed and aspiration/flush confirmed correct positioning. Weight-based doses were calculated for all medications administered.

Charting Tips
  • Document the number of failed IV attempts that justified IO placement. This establishes medical necessity. ACLS and ATLS guidelines support IO as first-line access in cardiac arrest and as second-line after one or two failed peripheral attempts in emergencies.
  • Document confirmation of correct placement by aspiration of marrow AND resistance-free flush. A misplaced IO that extravasates into soft tissue can cause compartment syndrome, and explicit confirmation documentation is critical.
  • IO access should be converted to conventional IV/central access as soon as clinically feasible. Document the time the IO was placed and the time it was removed. IO should not remain in place >24 hours due to infection risk.
Billing Tips
  • Bill 36680 for intraosseous catheter placement (1.17 wRVU, 0-day global). Covers manual, drill-based (EZ-IO), and impact-based (FAST1) IO devices. Technique does not change the code.
  • 0-day global: no bundled postoperative period. IO access is almost always part of a resuscitation where critical care (99291/99292) is the primary bill, and IO placement may be bundled into critical care time rather than billed separately.
  • When performed as a standalone emergent procedure (e.g., by surgery, EM, or anesthesia before a case), 36680 is separately billable. Document the indication, site, device, and confirmation of placement.
  • IO access is a temporary measure. When a central or peripheral IV is subsequently placed in the same encounter, only the definitive access code needs to be billed separately. IO and CVL in the same resuscitation are not typically both billed.