49421

Permanent Intraperitoneal Catheter Insertion (Open)

CPT 49421 describes the open surgical insertion of a permanent intraperitoneal cannula or catheter, which is most frequently performed for patients requiring long-term peritoneal dialysis or for the management of chronic, refractory ascites. The procedure typically involves the use of a Tenckhoff catheter, which is a flexible silicone tube featuring one or two polyester (Dacron) cuffs. The surgical process begins with the patient under general or regional anesthesia. A small incision is made, usually in the lower quadrant or midline of the abdomen. The surgeon carefully dissects through the skin, subcutaneous fat, and the anterior rectus sheath. The rectus muscle is either retracted or split to expose the posterior rectus sheath and the peritoneum. After a small incision is made into the peritoneal cavity, the distal tip of the catheter is advanced into the deepest part of the pelvis, often the rectus-vesical pouch in men or the pouch of Douglas in women, to ensure optimal fluid drainage. A purse-string suture is typically placed around the peritoneal entry site to provide a water-tight seal and prevent dialysate leakage. One Dacron cuff is often secured within or just above the rectus sheath to provide internal anchoring. The surgeon then creates a subcutaneous tunnel using a specialized tunneling tool, through which the proximal portion of the catheter is pulled. This tunnel terminates at a separate skin exit site, away from the primary incision, to minimize the risk of peritonitis and exit-site infections. The second Dacron cuff is positioned within this tunnel to promote tissue ingrowth and provide further anchoring and a bacterial barrier. The catheter is then tested for patency by flushing with saline and observing the return flow. Finally, the abdominal layers are closed in a standard fashion.

Clinical Indications

  • End-stage renal disease (ESRD) requiring peritoneal dialysis
  • Chronic kidney disease stage 5 as preparation for dialysis
  • Refractory malignant ascites requiring frequent therapeutic paracentesis
  • Chronic ascites due to cirrhosis when other treatments have failed

Procedure Steps

  1. Administration of anesthesia and surgical site preparation.
  2. Performance of a midline or paramedian abdominal incision.
  3. Dissection through subcutaneous tissue and abdominal fascia.
  4. Incision into the peritoneum and placement of the catheter's distal end into the pelvis.
  5. Securing the peritoneal opening with a purse-string suture to prevent leaks.
  6. Creation of a subcutaneous tunnel from the peritoneal entry to a separate skin exit site.
  7. Positioning of Dacron cuffs within the tunnel and fascia for anchoring and infection control.
  8. Testing the catheter for patency using inflow and outflow of saline.
  9. Closure of the primary surgical incision in layers.
  10. Application of a sterile dressing to the exit site and incision.

Coding Guidelines

  • Use 49421 for the open surgical technique only.
  • For percutaneous insertion under imaging guidance, see code 49418.
  • For laparoscopic insertion of a permanent intraperitoneal catheter, use code 49324.
  • Removal of a permanent intraperitoneal catheter is reported with code 49422.
  • Code 49421 includes the creation of the subcutaneous tunnel and cuff placement.
  • If imaging guidance is used during the open procedure, it is typically considered bundled or requires specific documentation for separate billing depending on the modality.
  • Do not report 49421 in conjunction with 49419 (temporary catheter).

Associated ICD-10 Codes