2011 Brings Wide Scale Cardiac Cath Changes

By David B. Dunn, MD, FACS, CIRCC, CPC-H, CCC

For 2011, CPT® has given cardiac catheterization (cath) coding an “extreme makeover,” to include:

• 19 deleted cardiac cath codes (93501, 93508, 93510, 93514, 93524, 93526, 93527, 93528, 93529, 93539-93545, 93555, and 93556)
• 20 new Category I codes (93451-93464 and 93563-93568)
• New injection codes and bundling issues related to congenital cath codes 93530-93533

Familiarizing yourself with the new codes and concepts will help you report these procedures accurately for correct reimbursement and compliance.

New Bundles Abound

CPT® 2011 consolidates radiological supervision and interpretation (S&I), and radiological report, into the heart cath and injection codes. Likewise, all cath codes include placement of vascular closure devices and any associated imaging, when performed. No longer are there separate codes, apart from the applicable cath and/or injection codes, to report these procedures/services.
Non-congenital caths now include left ventricular injections or ventriculography when performed: No additional code is reported for left ventriculogram (Lt. vgram) with non-congenital caths. A number of non-congenital cath codes also now include coronary angiography and bypass graft imaging.
All cardiac cath procedures include conscious sedation, sheath placement, catheter introduction and repositioning, recording of pressures, and intracoronary arterial injection of medications.

Non-Congenital Heart Caths

Now that we know what’s included, let’s review the new cath codes. We’ll start with the 11 non-congenital heart cath codes, and group them for easier understanding:
Note: For ease of understanding, we’ll use shortened code descriptors rather than the full CPT^® descriptors.
93451   Right heart cath (RHC) only
Note: No coronary angiography with 93451.
93452   Left heart cath (LHC) (+/– Lt. vgram)
93453   LHC + RHC (+/– Lt. vgram)
Note: No coronary angiography, only pressures and Lt. vgram when performed with 93452, 93453.
93454   Native coronary angiography only
93455   Native coronaries + bypass graft imaging
93456   Native coronaries + RHC
93457   Native coronaries + bypass graft imaging + RHC
Note: No LHC with 93454 – 93457.
93458   Native coronaries + LHC (+/– Lt. vgram)
93459   Native coronaries + LHC (+/– Lt. vgram) + bypass grafts
93460   Native coronaries + LHC (+/– Lt. vgram) + RHC
93461   Native coronaries + LHC (+/– Lt. vgram) + RHC + bypass grafts
Add-on Injection and Misc. Procedures
Three add-on injection procedure codes and three add-on miscellaneous codes may be used with the non-congenital cath codes. Imaging supervision is included.
+93566  Right ventricular and/or right atrial angiography
+93567  Supravalvular aortography
+93568  Pulmonary angiography
Note: Code 93566 is for right chamber injections only. Remember that left ventriculogram, when performed, is included in the appropriate non-congenital cath code.
Three miscellaneous codes also may apply:
+93462              LHC by transseptal or transapical approach
Note: Code 93462 is reported in addition to the appropriate non-congenital cath code. It also may be reported with ablations for supraventricular or ventricular tachycardia when a transseptal puncture is made to facilitate the ablation procedure (93651 Intracardiac catheter ablation of arrhythmogenic focus; for treatment of supraventricular trachycardia by ablation of fast or slow atrioventricular pathways, accessory atrioventricular connections or other atrial foci, singly or in combination or 93652 Intracardiac catheter ablation of arrhythmogenic focus; for treatment of ventricular tachycardia). Code 93462 is not reported with congenital heart caths.
+93463  Drug administration (e.g., nitrous oxide) with hemodynamic measurements before and after
Note: This code is not for coronary artery drug administration during interventions. Code +93463 may be reported only once per encounter.
+93464  Physiologic exercise study with hemodynamic measurements before and after
Note: This code may be reported only once per encounter.

Congenital Cath Codes

CPT® 2011 retains the four existing congenital cath codes:

93530   RHC only
93531   RHC & retrograde LHC
93532   RHC + transseptal LHC via an intact septum
93533   RHC + transseptal LHC via an existing septal opening
When reporting these codes, keep two points in mind:
1. Do not report +93462 (LHC by transseptal or transapical approach) with 93532 or 93533; the transseptal approach is included in these congenital cath codes.
2. Codes 93532 and 93533 include a retrograde LHC, if performed.
Codes describing injection procedures for congenital caths include:
+93563  Selective native coronary imaging
+93564  Selective bypass graft imaging
+93565  Selective left ventricular and/or left atrial
angiography
Note: Although 93563-93565 are to be used only with congenital cath codes, three additional codes may be used with either congenital or non-congenital cath codes:
+93566  Right ventricular and/or right atrial angiography
+93567  Supravalvular aortography
+93568  Pulmonary angiography

Related Cardiology Codes

A number of related cardiology codes may accompany cath claims:
93503  Insertion of a Swan-Ganz catheter for monitoring
Never report this code with right heart cath codes 93451, 93453, 93460, and 93461; placement of the Swan-Ganz catheter is inherent to the right heart cath. Rather, use this code for monitoring a critically ill patient in the intensive care unit (ICU), for example.
93505  Endomyocardial biopsy
Code 93505 is reported only once per session, even if more than one biopsy is obtained. A right heart cath performed for guiding the biopsy would not be reported, but if a complete RHC for separate medical necessity is performed, it may be reported.
93561  Dilution studies with cardiac output
measurement
93562  Subsequent cardiac output measurement
Never report these two codes with the right heart cath codes 93451, 93453, 93460, and 93461 because the services are inherent to the RHC. Instead, use these codes during monitoring of a critically ill patient in the ICU, when cardiac outputs are measured.

Coding Examples: 2010 vs. 2011

To illustrate how cath coding has changed, let’s use two examples to compare coding in 2010 to that in 2011.
Example 1: A patient undergoes a routine left heart cath, coronary angiography, and left ventriculogram.

This is one of the most common combinations of procedures performed in the cardiac cath lab and, as you can see, the codes reported have gone from five in 2010 to one in 2011. Code 93458 includes coronary angiography, as well as a left heart cath. Like the other non-congenital cath codes, a left ventriculogram is included, when performed.
Example 2: A patient undergoes a left and right heart cath and a coronary angiography, left and right ventriculography, saphenous vein bypass graft imaging, left internal mammary graft imaging, and supravalvular aortography. A vascular closure device was placed at the conclusion of the procedure.

In 2011, code 93461 includes the LHC, RHC, coronary angiography; bypass graft imaging including the saphenous vein, internal mammary artery (IMA), and left ventriculogram. Code 93566 is reported additionally for the right ventriculogram, and 93567 is reported for the supravalvular aortogram. All the 2011 codes include imaging S&I, as well as vascular closure device placement and all associated imaging.
Wide scale changes for 2011 are here, but with diligent use of these codes, cardiac cath coding will become easier because fewer codes in general will be required to report each case. It is imperative to learn the new concepts introduced in 2011, and carefully note exactly which procedures are included with each new cath code.

Heart Cath Terminology

Accurate code selection begins with knowing the definitions for common heart cath terminology.

• A left heart catheterization (LHC) involves entry into the left side of the heart (left atrium, left ventricle) for pressure measurements.
• A right heart catheterization (RHC) involves access via the venous system into the right side of the heart (right atrium, right ventricle, and pulmonary arteries) for obtaining blood samples, and pressure and cardiac outputs.
• Ventriculography is the injection of contrast into the right and/or left ventricle(s) to visualize these chambers and to study function of these chambers.

David Dunn, MD, FACS, CIRCC, CPC-H, CCC, is vice president of ZHealth. He oversees physician coding, instructs for ZHealth educational programs, and contributes to Dr. Z’s Medical Coding Series. A graduate of Texas A&M University, he completed his M.D. at the University of Texas, his surgical residency at Scott & White Hospital, and his vascular surgery fellowship at Baylor College of Medicine. A diplomat of the American Board of Surgery, Dr. Dunn is also certified in vascular surgery. He is a fellow of the American College of Surgeons and a member of the Southern Association for Vascular Surgery. He is president-elect of the AAPC National Advisory Board (NAB).
 

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