Dissecting Diagnostic Cardiac Catheterization Reports 

Dissecting Diagnostic Cardiac Catheterization Reports 

Reading the body of the report thoroughly will help you apply appropriate code combinations and modifiers.

To code properly, you must know how to read the body of the operative report. Let’s break down the documentation for a percutaneous diagnostic non-congenital cardiac catheterization to better understand what you must abstract from a report to code appropriately.

Indications

The provider must document the indications in their catheterization note. The indications will help to justify medical necessity. Medicare and most insurance companies require medical necessity for any service provided to a patient. If the patient’s catheterization results are normal, the indications must support medical necessity for reimbursement of the diagnostic catheterization.

Indications also help you to understand what is happening with the patient. For example, if the patient is brought to the catheterization lab for a cardiac catheterization within 90 days of having a pacemaker or implantable cardioverter-defibrillator inserted, you’ll need to know which global modifier to append to the CPT® code.

Included Services

Non-congenital diagnostic cardiac catheterizations are coded from CPT® code range 93451-93464. All diagnostic catheterizations include:

  • The introduction, positioning, and/or repositioning of the catheter within the vascular system;
  • Road mapping angiography, recording of intracardiac and/or intravascular pressures;
  • Intraprocedural injection for angiography;
  • Supervision and interpretation of angiography; and
  • Contrast injection to image the access site for placing a closure device.

Moderate sedation is included when performed by the same provider who performs the catheterization. If a second provider is necessary to provide moderate sedation, the additional provider may perform and bill for the service, as long as:

  1. The provider is not also functioning as an assistant on the cardiac procedure; and
  2. The procedure is performed in the facility setting.

Report

For coding purposes, the documentation should include:

  • The providers who are involved in the case
  • Indications of the performed procedure
  • Access site
  • Catheter placement and repositioning
  • Angiogram findings
  • Pressure recordings (when performed)
  • Complications (if any)
  • Drug(s) administered (name, dosage, route, site)
  • Closure device
  • Recommendations
  • In the event there is a hematoma at the access site, document the size of the hematoma in centimeters.

Note: Hospitals and the Centers for Medicare & Medicaid Services (CMS) specify guidelines regarding appropriate documentation, such as two patient identifiers, prep, toleration of procedure, etc. You must follow these guidelines, as well.

It doesn’t matter if the physician neglects to list the procedure in the report heading because it’s incorrect to code from the heading of a report.

Coronary Catheterization

For CPT® 93454 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, the physician will access the vascular system, most commonly through a femoral artery on the right side (other possible access sites include left femoral or brachial access). She place the catheter into the left coronary artery for injection and imaging, and then into the right coronary artery for injection and imaging. The physician will include the closure, angiography findings, and an impression. CPT® code 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 includes the same steps, plus the catheter placement in the bypass graft for injection and angiogram, with documentation of the angiographic findings.

Right Heart Catheterization

Right heart catheterization includes all of the aforementioned services, with the introduction of the catheter into one or more right-sided cardiac chamber(s) or structure(s), obtaining blood samples for measurement of blood gases, and cardiac output measurements. A right heart catheterization can be performed:

  • Alone, using 93451 Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed;
  • With coronary angiography, using 93456 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization; or
  • With coronary angiography and bypass graft angiography, using 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.

You must abstract the same information for the right heart catheterization with coronary angiography and/or bypass graft angiography as that abstracted for the coronary angiography or coronary angiography with bypass graft angiography, with the addition of the placement of the catheter into the right-sided chamber or structure of the heart. Key words that indicate the catheter is on the right side include right atrium, right ventricle, pulmonary artery, or pulmonary wedge. The physician will also document the measurements taken during the procedure.

Left Heart Catheterization

Just like right heart catheterization, left heart catheterization includes all of aforementioned services, plus the introduction of the catheter into the left-sided cardiac chamber and left ventriculography. A left heart catheter can be performed:

  • Alone, as reported using 93452 Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed;
  • With coronary angiography, using 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; or
  • With coronary angiography and bypass graft angiography, using 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) including intraprocedural injection(s) for bypass graft angiography.

You must abstract the same information for the left heart catheterization with coronary angiography and/or bypass graft angiography as that abstracted for the coronary angiography or coronary angiography with bypass graft angiography, along with placement of the catheter into the left side of the heart. The physician will also document if a left ventriculogram is performed, with the findings. Because the code descriptors stipulate “when performed,” coding doesn’t change if the ventriculogram is not performed; you can still code the left heart catheterization.

Combined Right and Left Heart Catheterization

Following the established pattern, a combined right and left heart catheterization includes all of the services listed above, with the introduction of the catheter into the right-sided chamber or structure of the heart and catheter placement into the left-sided cardiac chamber and left ventriculography. The combined right and left heart catheterization can be performed:

  • Alone, using 93453 Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed.
  • With coronary angiography, by reporting 93460 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.
  • With coronary angiography and bypass graft angiography, as reported by 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) including intraprocedural injection(s) for bypass graft angiography.

Angiographic Findings

Typically, angiographic findings will list the main coronary arteries: left main, left circumflex, left anterior descending, right coronary, and/or the ramus intermedius. When the provider also visualizes stenosis in the branches, they will document the branch. Most physician reports are neatly organized by main coronary, with its branches included in the section. For example:

1. The left main artery is free of disease.

2. The left anterior ascending artery contains 80 percent stenosis in the first diagonal branch distally.

3. The left circumflex artery is free of disease.

4. The right coronary artery gives off to the posterior descending artery with 50 percent stenosis.

Documentation in this form is very helpful when coding interventions and when appending an appropriate coronary modifier(s) for interventions performed on the branches of the main coronary arteries.

Add-on Procedures

Although diagnostic cardiac catheterization codes include the catheter placement, injection, and supervision and interpretation, some services can be coded in addition to the catheterization codes. Table A identifies add-on codes with their corresponding primary code.

Table A: Add-on codes with their corresponding primary code

ADD-ON CODES
93462 93463 93464 93566 93567 93568
93454 X
93455 X
93451 X X X X
93456 X X X X X
93457 X X X X X
93452 X X X
93458 X X X X
93459 X X X X
93453 X X X X X X
93460 X X X X X X
93461 X X X X X X

+93462 Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (List separately in addition to code for primary procedure)

Transseptal puncture is included in a right heart catheterization, and is not separately reportable

+93463 Pharmacologic agent administration (eg, inhaled nitric oxide, intravenous infusion of nitroprusside, dobutamine, milrinone, or other agent) including assessing hemodynamic measurements before, during, after and repeat pharmacologic agent administration, when performed (List separately in addition to code for primary procedure)

Do not confuse pharmacologic agent administration with the injection of the dye needed to perform an angiogram.

+93464 Physiologic exercise study (eg, bicycle or arm ergometry) including assessing hemodynamic measurements before and after (List separately in addition to code for primary procedure)

+93566     for selective right ventricular or right atrial angiography (List separately in addition to code for primary procedure)

+93567     for supravalvular aortography (List separately in addition to code for primary procedure)

The physician should document the catheter is positioned into the aortic root with angiogram findings for the aortic valve, aortic root, and the ascending aorta.

+93568 for pulmonary angiography (List separately in addition to code for primary procedure)

The catheter is passed through the right atrium into the right ventricle, and then into the main pulmonary artery or one of the pulmonary branches.

The following add-on codes can be listed in addition to diagnostic codes 93454-93461:

+93571 Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; initial vessel (List separately in addition to code for primary procedure)

+93572 each additional vessel (List separately in addition to code for primary procedure)

+92973 Percutaneous transluminal coronary thrombectomy mechanical (List separately in addition to code for primary procedure)

+92974 Transcatheter placement of radiation delivery device for subsequent coronary intravascular brachytherapy (List separately in addition to code for primary procedure)

+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)

+92979 each additional vessel (List separately in addition to code for primary procedure)

+0291T Intravascular optical coherence tomography (coronary native 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)

+0292T each additional vessel (List separately in addition to code for primary procedure)

Modifiers

Be sure to check the Medicare Physician Fee Schedule to verify which CPT® codes require modifier 26 Professional component for procedures performed in the hospital setting.

Remember also, either modifier 59 Distinct procedure service or one of the newly created subset modifiers (XE Separate encounter, XP Separate practitioner, XS Separate structure, XU Unusual non-overlapping service) is needed when a diagnostic catheterization and intervention are performed on the same date of service. Read the guidelines to understand when you can bill both with a modifier.

Example

(This note has been summarized to identify correct coding.)

A JL-5 catheter was advanced to the left coronary artery, and left coronary arteriograms were performed in multiple views. The catheter was then removed, a JR-4 catheter was advanced over the guidewire and used to engage the right coronary artery, and right coronary arteriograms were performed in multiple views. The JR-4 catheter was then withdrawn and used to engage the saphenous venous graft to the obtuse marginal, and angiographic images were obtained in multiple views. The catheter was advanced past the aortic valve, and left ventricular pressures were obtained. At completion of the procedure all catheters and wires were removed. (The physician also documented findings in the coronary arteries, saphenous venous graft and pressures, consent, prep, indications access, closure, and impression.)

Coding: 93459-26. Modifier 26 is used because the procedure was performed in the catheterization laboratory in the hospital. The catheter crossing the aortic valve into the left ventricle to record pressures signifies a left heart catheterization was performed. A left ventriculogram was not documented, but the code description includes a left ventriculogram, when performed. The provider also places the catheter in both of the coronary arteries and the saphenous vein graft. He documents all of the findings in his note. This is a left heart catheterization with coronary and bypass graft angiograms.

Example

A 4-French JL-4 catheter was advanced over a wire and used to engage the left coronary artery system, and coronary angiography was performed in multiple views. The catheter was then exchanged for 4-French JR-4 catheter. The catheter was used to engage the right coronary artery, and coronary angiography was performed in multiple views. At completion of the procedure, all wires, catheters, and sheaths were removed, and hemostasis was obtained with manual compression. (The physician also documented findings in the coronary arteries, consent, prep, indications access, closure, and impression.)

Coding: 93454-26. Modifier 26 is appended to bill for the physician’s professional component of the service performed in the hospital setting. The physician placed the catheter into both coronary arteries and documented the findings. This is a coronary catheterization.

To ensure you are coding accurately, always read the CPT® guidelines preceding the codes; and read the parenthetical notes following the codes to ensure you are selecting appropriate code combinations.

What Encompasses Attorney/Client Privilege During an Audit?

Understand the confidentiality principles that apply in attorney/
client interactions.

Question: What is attorney/client privilege in terms of audits, and how and when should it be used?

Answer: Healthcare fraud costs the federal government billions of dollars annually. Such costs have led to increasing federal scrutiny of healthcare providers, as well as tough positions against the attorney/client confidentiality protections afforded to healthcare providers who hire a lawyer to protect their interests (see Principles of Federal Prosecution of Business Organizations). In light of evolving trends, let’s clarify important legal concepts for coding professionals.

Coding Tip: Do not report 93503 Insertion and placement of flow directed catheter (eg Swan Ganz) for monitoring purposes in addition to a diagnostic heart catheterization.

Confidentiality Principles

The attorney/client confidentiality principles, as set forth in American Bar Association Model Rule 1.6, consists of two principles: the attorney/client privilege and the work product doctrine — both of which serve to protect client communications and encourage a full and candid conversation regarding the events leading to the need for legal counsel. These principles are based on the fact that effective representation requires the lawyer to be informed of all facts, both the good and the bad, to evaluate a client’s case.

The attorney/client privilege protects the communications between a lawyer and their client. This can include not only verbal communications but also written communication, such as correspondence or emails between lawyer and client. For example, an email from the client to the attorney seeking a legal opinion on a Medicare coverage requirement is privileged.

The work product doctrine protects an attorney’s notes, records, and reports that are either drafted by the attorney or developed at the attorney’s direction in the course of representing the client. For example, a coding audit conducted at an attorney’s request to identify an overpayment falls within this interpretation.

What Invokes Privilege?

Although these examples seem straightforward, the confidentiality principles do not apply in all attorney client interactions. The privilege and its protections only come into play when the client is seeking legal advice. Day-to-day communications with an attorney on mundane issues or business topics, having an attorney attend staff meetings, or copying an attorney on an inter-office email does not invoke privilege. The client communication must be directed to the attorney and must be for seeking legal advice. Similarly, the work product doctrine applies to the documents developed by the attorney or at the attorney’s direction. Pre-existing documents, such as Explanation of Benefits, patient medical records, or billing statements are not protected as work product, and giving such documents to an attorney doesn’t make it so.

Providers should help ensure adequate protections by developing a policy for responding to government inquiries, including how and when attorney/client communications and the work product doctrine come into play.


Julie E. Chicoine, Esq., RN, CPC, CPCO, is senior vice president and general counsel for the Texas Hospital Association. She earned her Juris Doctor degree from the University of Houston Law Center. Chicoine also holds a Bachelor of Science and nursing degrees from the University of Texas Health Sciences Center at Houston. She writes and speaks widely on healthcare issues, and is an active member of the AAPC community and Legal Advisory Board.

Angela Clements, CPC, CPC-I, CEMC, COSC, CCS, is the physician coding auditor/educator consultant at Medkoder. She has over 17 years of experience in the healthcare industry. Clements serves on the AAPC National Advisory Board (NAB) as the member relations officer, has served on the NAB as Region 5 representative from 2013-2015, and is involved in the Covington, La., local chapter. She is a well-rounded, knowledgeable coding resource with extensive experience in multi-specialty coding, documentation, and auditing. Clements is a frequent speaker at local medical managers’ meetings, as well as other AAPC local chapters in her region.

Resources

To access the Medicare Physician Fee Schedule for appropriate usage of modifier 26, go to:
www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

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Angela Clements

Angela Clements

Physician Coding Auditor, Educator & Consultant at Medkoder
Angela is a Physician Coding Auditor, Educator& Consultant at Medkoder. She has over 18 years of experience in the healthcare industry. Clements serves on the AAPC NAB as the Member Relations Officer and served as Region 5 Representative from 2013-2015. She is a frequent speaker at local medical managers' meetings and local chapters in her region.
Angela Clements

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Angela is a Physician Coding Auditor, Educator & Consultant at Medkoder. She has over 18 years of experience in the healthcare industry. Clements serves on the AAPC NAB as the Member Relations Officer and served as Region 5 Representative from 2013-2015. She is a frequent speaker at local medical managers' meetings and local chapters in her region.

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