Resuscitate Your Cardiac Catheterization Coding

Following the rules will ensure proper coding and reimbursement.

Cardiac catheterization is performed to diagnose coronary artery disease, valvular heart disease, angina (chest pain), congestive heart failure, and certain congenital (present at birth) heart conditions. Ensure your providers are correctly reimbursed for these diagnostic techniques by understanding what these procedures involve and the requirements for coding them.

Understand the Procedure

During cardiac catheterization, a small, flexible tube called a catheter is placed into a blood vessel in the patient’s arm, groin (upper thigh), or neck, and advanced through the aorta into the heart. The tip of the catheter can be placed in various parts of the heart, or advanced to the coronary arteries. This is followed by an injection of contrast dye through the catheter into the arteries. This test, coronary angiography, allows the physician to locate blockages in the coronary arteries.
The dye can show whether a waxy substance called plaque has built up inside the coronary arteries. Fatty deposits may develop in childhood and continue to thicken and enlarge throughout life. Atherosclerosis (a buildup of plaque in the inner lining of an artery, causing it to narrow or become blocked) is the most common form of coronary artery disease.

Break Down the Catheterization Codes

To better understand catheter placement code assignment, we’ll review several key codes and guidelines.
93451 Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed

• The catheter is advanced through the inferior or superior vena cava into the right atrium, then into the right ventricle, pulmonary artery, and pulmonary capillary wedge positions for pressure measures.
• Swan-Ganz catheter, a flow-directed catheter, should not be reported with 93503 Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes with any right heart catheterization procedure. Report 93503 when the Swan-Ganz is placed for monitoring purposes only.
• To report right atrial angiography or right ventricular angiography, assign add-on code 93566 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective right ventricular or right atrial angiography (List separately in addition to code for primary procedure) to 93451, 93453, 93456, 93457, 93460, 93461 and congenital heart disease (CHD) catheterizations.
• Other codes that include a right heart catheterization are 93453, 93456, 93457, 93460, and 93461. Do not report 93451 separately with any of these codes.

93452 Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed

• Documentation should indicate crossing of the aortic valve, and that the pressures are from inside the left heart chamber.
• Code 93452 includes imaging supervision and interpretation for left ventricular or left atrial angiography.
• Other codes that include a left heart catheterization are 93453 and 93458-93461. Do not report 93452 separately with any of these codes.

93453 Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed

• Code 93453 includes all left heart catheterization components, including the function of the mitral valves, aortic valves, and aortic valve regurgitation.
• For right and left heart catheterization with coronary angiography, refer to 93460.
• For bypass graft angiography, use 93461 (description follows).

93454 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation

• The coronary arteries arise from the aorta just above the aortic valve, so the physician can place the catheter into the coronary arteries without entering the heart.
• When the physician uses injections for guidance only, do not separately code the injection.

Bypass graft catheterization codes include:
93455 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography
93457 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization
93459 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography
93461 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography

• Coronary artery bypass grafts include vein grafts, internal mammary artery grafts, and free arterial grafts.
• When the origin of any of these grafts is engaged, you should assign a code that includes bypass graft catheterization.
• Internal mammary artery (non-grafted) injection (to determine whether it’s suitable for use in future bypass surgery) is coded as a bypass graft catheterization, even though the artery has not yet been grafted.

Appropriately Apply Add-ons

Intravascular ultrasound (IVUS) is an additional technique that may be employed during a cardiac catheterization. IVUS uses a computer and a transducer to transmit ultrasonic sound for direct visualization and measurements of the inside of blood vessels, and may assist the physician in selecting an appropriate treatment. Report IVUS with add-on codes 92978 Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel (List separately in addition to code for primary procedure) and 92979 Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; each additional vessel (List separately in addition to code for primary procedure). Claim the coronary IVUS codes one time per vessel, even if multiple exams are performed in a vessel.
Other potential add-on procedures with cardiac catheter placement include:

• Suparavalvular aortography +93567 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for supravalvular aortography (List separately in addition to code for primary procedure) describes positioning a catheter in the aortic root and injecting contrast. The resulting angiograms show the aortic valve, the aortic root, and the ascending aorta.
• Pulmonary angiography +93568 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for pulmonary angiography (List separately in addition to code for primary procedure) describes passing a catheter through the right atrium into the right ventricle, and then into the main pulmonary artery or one of its branches. Report this add-on code in addition to 93451, 93453, 93456, 93457, 93460, 93461, and CHD heart catheterization codes.

Watch Out for Bundled Services

The following services are included in cardiac catheterizations and are not coded separately:

• Local anesthesia and moderate sedation
• Insertion, positioning, repositioning, and removal of catheters into the coronary arteries and/or left and/or right heart
• Mapping angiography performed to place the catheters
• Recording of pressures in the heart chambers and blood vessels
• Angiography for closure device placement
• Evaluation and interpretive report

Do not assign a separate injection code for a type of injection that is already included in the catheterization code.

Coding Examples Show the Way

Consider the following examples of proper coding for catheter placement.
Example 1: A critically ill patient requires continuous cardiac monitoring. In the intensive care unit, a Swan-Ganz catheter is inserted into the jugular vein and advanced through the right atrium, right ventricle, and pulmonary artery to a wedged position. Blood samples are taken, pressures and recordings are obtained, and the catheter is left in place for continuous monitoring for two days.
Because the catheter is placed for monitoring only, correct coding is 93503.
Example 2: A 6-French sheath and catheter is inserted into the right femoral artery and a catheter is advanced to the left ventricle. Ventriculography is performed using power injection of contrast agent. Pressures in the left heart are obtained. Additionally, the coronary arteries are selected and imaged.
In this case, correct coding is 93458 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed for left ventriculography.
Example 3: A 7-French sheath and catheter is inserted into the right common femoral artery. The catheter is advanced through the inferior or superior vena cava into the right atrium, into the right ventricle, and then into the pulmonary artery.
Because this is a right heart catheterization, the appropriate code is 93451.

Answer Five Questions Before Coding

1. Which set of CPT® codes apply? There are two sets of cardiac catheterization codes: One for congenital heart disease, and one for all other conditions.
Caution: Do not use congenital codes (93530-93533) if the patient’s only congenital anomaly is coronary arteries, patient foramen ovale, mitral valve prolapse, or bicuspid aortic valve: These types of anomalies are very common.
2. Which side(s) of the heart was the catheterization performed on: right, left, right and left, or only the coronary arteries?
Tip: When a study is performed for a congenital anomaly, the right side of the heart will almost always be studied.
3. What technique was used? A retrograde (opposite the direction of blood flow) approach is performed most often for coronary arteries and left heart catheterizations. The antegrade (in the same direction of blood flow) approach is more common for right heart catheterization.
4. Were there any add-on procedures?
5. What was the place of service? For example, are you coding for professional component billing (modifier 26 Professional component) or the hospital Outpatient Prospective Payment System, which assigns codes to a payable ambulatory payment classification?

Educate Physicians About
Documentation Requirements

All coding must be supported by the documentation in the medical record. To improve your chances of selecting the appropriate cardiac catheter code, and of gaining the best possible appropriate reimbursement, educate your providers to document all pertinent information, including:

• History (e.g., acute myocardial infarction), medical necessity, and reason for repeat diagnostic studies after prior angiography/computed tomography/magnetic resonance angiography (angio/CT/MRA)
• Vascular access sites:
• Arm (becoming more popular, less recovery time)
• Groin (upper thigh: most common, requires 2-6 hours of bed rest)
• Neck
• Vessels catheterized, describing the catheter tip location, and any variant anatomy
• Heart pressures and chambers entered, injected, and imaged
• Vessels injected, the areas imaged (for medical necessity), with interpretation of findings (e.g., Is it a chronic total occlusion (CTO)?), along with specific documentation of degree stenosis and exact locations of the treated lesions
• Interventions performed, and any complications or additional treatments provided
• Specific devices and specialty supplies used during the procedure

Source: Adapted from ZHealth Publishing with permission.

Lynn Stuckert, LPN, CPC, CPMA, has 30 years of experience in large multi-specialty clinics and hospital systems as a nurse, chart auditor, educator, compliance manager, and medical writer. She has held offices for AAPC’s City of Palms Chapter, Fort Meyers, Florida, and the Health Management Association of Southwest Florida.

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