Tunneled Dialysis Catheter (Permcath)

CPT 36558
Approach Endovascular
Add-on / Variant CPTs
  • 36561 — Insertion of tunneled centrally inserted central catheter, age 5 or older
  • 75860 — Venography, jugular/subclavian, radiologic S&I
Preoperative Diagnosis:

End-stage renal disease requiring hemodialysis — no usable AV access; tunneled hemodialysis catheter for dialysis initiation

Postoperative Diagnosis:

Same

Procedure Performed:

Right [left] internal jugular vein tunneled hemodialysis catheter (Permcath) placement

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

Local — [X] mL 1% lidocaine with epinephrine at access and tunnel sites [/ MAC]

Indications:

The patient is a [age]-year-old [male/female] with end-stage renal disease requiring urgent initiation of hemodialysis. [AV fistula / graft is not yet mature / no suitable access sites / maturing fistula not yet cannulatable.] A tunneled hemodialysis catheter was placed as a bridge to permanent access. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

The right internal jugular vein was patent and compressible on ultrasound. The catheter tip was confirmed by fluoroscopy at the [cavoatrial junction / right atrium]. Blood flow rates of [350–400 mL/min] were confirmed. No pneumothorax or vascular injury on post-procedure imaging.

Description of Procedure:

The patient was positioned supine in Trendelenburg with the head turned to the left. The right neck, chest, and anterior chest wall were prepped and draped in sterile fashion. Local anesthesia was infiltrated at the right internal jugular vein access site and along the planned subcutaneous tunnel.

Under real-time ultrasound guidance, the right internal jugular vein was accessed with an [18-gauge] needle. A [0.035-inch] guidewire was advanced into the superior vena cava under fluoroscopic guidance. The wire position was confirmed in the SVC. The skin was incised and the tract dilated.

The subcutaneous tunnel was created using the tunneling device from the anterior chest wall exit site to the venous access site. The [15.5 Fr] [Mahurkar / HemoSplit / Palindrome] tunneled catheter was pulled through the tunnel so the Dacron cuff lay in the subcutaneous tunnel [approximately 2 cm from the exit site].

The peel-away sheath was advanced over the wire under fluoroscopy and the catheter was inserted through the sheath into the SVC. The catheter tip was positioned under fluoroscopy at the [cavoatrial junction / right atrium]. The peel-away sheath was removed. The catheter was sutured to the skin at the exit site with [3-0 Prolene] and locked with [heparin / citrate] solution.

Fluoroscopic confirmation of catheter tip position at the cavoatrial junction. Both lumens were aspirated and flushed — brisk blood return and flush without resistance confirmed. Post-procedure chest X-ray [was obtained / fluoroscopic imaging confirmed no pneumothorax].

Complications:

None

Specimens:

None

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

The patient tolerated the procedure well. Both catheter lumens were functioning with brisk blood return. The catheter was ready for immediate dialysis use. Dialysis nursing was notified. AV access planning was discussed for long-term transition.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: ESRD — dialysis initiation, no mature AV access
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right *** tunneled hemodialysis catheter placement
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Local with MAC

INDICATIONS: .PTAGE-year-old .PTSEX with ESRD requiring dialysis. ***. Consent obtained.

FINDINGS: Right IJV patent on ultrasound. Catheter tip at cavoatrial junction on fluoroscopy. Both lumens functional.

PROCEDURE:
Supine, Trendelenburg, head left. Right neck/chest prepped. Local anesthesia infiltrated. Ultrasound-guided right IJV access, 18-gauge needle. Wire into SVC, fluoroscopy confirmed. Tract dilated. Tunnel created, anterior chest to access site. *** Fr *** catheter pulled through tunnel, cuff *** cm from exit. Peel-away sheath, catheter advanced to cavoatrial junction under fluoroscopy. Sheath removed. Secured with 3-0 Prolene. Locked with ***. Both lumens aspirated — brisk return. Fluoroscopy: tip at cavoatrial junction, no pneumothorax.

EBL: Minimal
COMPLICATIONS: None
DISPOSITION: Both lumens functional. Dialysis notified.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Tunneled Catheter Exchange Over Wire

The existing dysfunctional tunneled catheter was exchanged over a guidewire. The cuff was freed from the subcutaneous tunnel using blunt dissection. A [0.035-inch] wire was advanced through the existing catheter into the SVC under fluoroscopy. The old catheter was removed over the wire. A new [15.5 Fr] tunneled catheter was placed through a new subcutaneous tunnel [or the same tunnel if not infected]. The tip was repositioned at the cavoatrial junction. Catheter exchange over wire is appropriate for catheter dysfunction without infection; a new tunnel site is required if catheter-related bloodstream infection is present.

Femoral Tunneled Catheter (IJ/Subclavian Exhausted)

Given bilateral internal jugular and subclavian occlusion on prior imaging, the right [left] femoral vein was used for access. The catheter was tunneled from the femoral exit site along the medial thigh. The tip was positioned in the inferior vena cava at the level of the [iliac confluence / right atrium via IVC]. Femoral catheters carry higher infection rates and are associated with ipsilateral DVT; this approach was used given lack of upper body venous access.

Charting Tips
  • Document catheter tip position specifically. 'Cavoatrial junction' or 'right atrium' is required. Catheter tip in the SVC (too proximal) results in inadequate flow rates and high recirculation. Tip in the right ventricle risks arrhythmia. Document the fluoroscopic landmark used for tip placement.
  • Document both lumens aspirating with brisk blood return before leaving the room. A tunneled catheter that does not aspirate freely at insertion will not function for dialysis and requires repositioning or replacement before the patient returns for their session.
  • Document the cuff position in the tunnel. The Dacron cuff should be 2–3 cm from the exit site. A cuff too close to the skin surface will extrude; a cuff too deep may not anchor adequately. This detail matters if the patient later develops cuff extrusion.
Billing Tips
  • 36560 (tunneled central venous catheter with subcutaneous port, 5.89 wRVU) vs 36561 (tunneled CVC without port, 5.65 wRVU). Dialysis catheters (Tesio, PermCath) use 36561 or 36566 depending on configuration.
  • 36566 (tunneled CV catheter with subcutaneous pump, 6.13 wRVU) is for dual-lumen tunneled hemodialysis catheters (e.g., PermCath). This is the most common code for dedicated dialysis access catheters.
  • 36563 (5.84 wRVU) covers tunneled catheters with fibrin sheath stripping or other modification. Use for catheters placed with concurrent thrombolysis or sheath disruption.
  • Replacement of existing tunneled catheter: 36581 (without port, 3.15 wRVU) or 36582 (with port, 4.87 wRVU). These are lower-weighted because exchange uses an existing tunnel.
  • Imaging guidance (fluoroscopy, ultrasound) is bundled into tunneled catheter placement codes. Do not separately bill 76937 or 77001.
  • Global period is 10 days (minor). Routine post-placement care, suture removal, and catheter flushes within 10 days are bundled.
  • Document access site, vein used (right IJ, subclavian, femoral), laterality, catheter brand/size/length, tip position on fluoroscopy, and indication (ESRD, bridge to maturation). All are required for payer documentation and ESRD network reporting.