Keep Your Cardiac Cath Coding Compliant

Knowing what cardiac catheterization CPT® codes include is half the battle.

The first known cardiac catheterization (cath) performed on a living person occurred in 1929 in Germany when Dr. Werner Forssmann, age 25, passed a 65 cm catheter through one of his own left antecubital veins and guided it using fluoroscopy until it entered his right atrium. Interventional cardiology procedures have come a long way since Forssmann’s first venture, and cardiac catheterization remains the gold standard for the detection and diagnosis of coronary artery disease today.

Currently, more than 1 million heart catheterizations are performed annually in the United States. A cardiac cath can be used for both diagnostic and therapeutic purposes. This procedure is commonly done to evaluate and manage conditions such as:

• Coronary artery disease
• Heart failure
• Left ventricular dysfunction
• Cardiac arrhythmia
• Valvular heart disease
• Pericardial and myocardial diseases
• Congenital heart disease
• Hemodynamic abnormalities in the right and left sides of the heart

There are two code families for cardiac catheterization: one for congenital heart disease and one for all other conditions. Understanding the components of cardiac catheterization is imperative for accurate procedural coding as well as auditing. It’s important to read the entire body of the procedure report and not rely solely on the title of the report for correct coding.

Let’s take a closer look at the indications and coding for these procedures.

Diagnostic Left Heart Catheterization

Indications for left heart catheterization (non-congenital) include:

• Evaluation and treatment of coronary artery disease (CAD)
  • Evaluation and treatment of CAD in patients with chest pain of uncertain origin when noninvasive tests are positive or inconclusive
• Assessment of coronary artery bypass graft(s)
• Evaluation and treatment of cardiac arrhythmias
• Assessment of severity of valvular disorders (aortic stenosis, aortic insufficiency, mitral stenosis, mitral insufficiency) and myocardial disorders (cardiomyopathies)
• Treatment of valvular heart disease (valvuloplasty, percutaneous transcatheter valve replacement)

Use the following three CPT® codes when only the left side of the heart is being examined:

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

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

93459              … catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography

Report 93452 when coronary angiography is not performed during the left heart cath. When coronary angiography is performed during left heart catheterization, use 93458. Look to code 93459 when coronary and bypass graft angiography are performed. All three codes include left ventriculography (LVG), when performed. In all three codes, catheter placement, contrast injections, administration of procedural sedation, imaging supervision and interpretation, and report are included. Append modifier 26 Professional component to these codes when billing for just the professional component performed by the physician.

Left ventriculography provides an assessment of left ventricular systolic function, degree of mitral regurgitation, and the presence of a wall motion abnormality or a ventricular septal defect. When LVG is performed, you should see documentation stating that the catheter was advanced across the aortic valve and into the left ventricle. The procedure report might state:

A pigtail catheter was advanced over a J-tipped wire to a position in the ascending aorta superior to the aortic valve. The catheter was advanced across the valve orifice and into the ventricle. An image was taken to assess the anterior wall, inferior wall, left ventricular apex, septum, and ventricular septal defects.

For diagnostic coronary angiograms, the report should reference that the diagnostic catheter was advanced over a curved guidewire under fluoroscopy. Once the catheter reached the ascending aorta, the wire was taken out and pressures were recorded. The left main and right coronary arteries were engaged, and multiple images were taken from different projections for each artery.

Diagnostic Right Heart Catheterization

Right heart catheterization (non-congenital) is indicated to evaluate:

• Valvular heart disease
• Congestive heart failure
• Cor pulmonale
• Pulmonary hypertension
• Intracardiac shunts (including septal rupture) and extracardiac vascular shunts
• Suspected cardiomyopathy, myocarditis
• Endocarditis anticipated to require valvular surgical repair
• Suspected rejection of a transplanted heart
• Suspected pericardial tamponade or constriction
• Congenital heart disease

Use the following three CPT® codes when only the right side of the heart is being examined:

93451   Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed

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

93457              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

In the right heart catheterization procedure report, the provider should document the right atrial, right ventricular, pulmonary artery, and pulmonary capillary wedge pressures, as well as cardiac output, cardiac index, and oxygen saturations. If they perform coronary angiography during the right heart catheterization, a description of the patency of the coronary arteries should also be documented.

Diagnostic Left and Right Heart Cath

Combined left and right heart catheterization (non-congenital) is performed to evaluate the cardiac function of both the right and left sides of the heart. In right heart catheterization, the provider inserts the catheter through an introducing sheath and threads it into the right atrium, through the tricuspid valve, into the right ventricle, and across the pulmonary valve into the pulmonary arteries. Then, left heart catheterization is performed using a retrograde technique in which the catheter is passed through the aortic valve into the left ventricle. Intracardiac and intravascular pressures are recorded.

Use the following three CPT® codes when both the right and left sides of the heart are being examined:

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

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

93461              … catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography

Note that all three codes include intraprocedural injections for left ventriculography. Remind your provider that if coronary angiography is performed, the medical record should include documentation of the patency of the coronary arteries. Append modifier 26 to these codes when appropriate.

Additional Injections and Procedures

Injections

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)

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

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

Report an injection procedure for right atrial, right ventricular, aortic, or pulmonary angiography performed in conjunction with cardiac catheterization in addition to the appropriate catheterization code. Make sure to document the diagnostic codes to support medical necessity. As with the prior codes, append modifier 26 when appropriate.

Swan-Ganz Placement

93503   Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes

This procedure involves a catheter being threaded through a central intravenous line into the right side of the heart and the arteries leading to the lungs. Although newer noninvasive technologies, such as echocardiography, may be used in place of Swan-Ganz, in some cases, clinicians still use a Swan-Ganz catheter for the following circumstances:

• Acute respiratory distress syndrome; certain cases
• Myocardial infarction; certain cases
• Diagnose right ventricle failure
• Distinguish between pre- and post-capillary pulmonary hypertension
• Monitor supportive therapy for patients in cardiogenic shock
• Severe chronic heart failure requiring therapy such as vasodilator
• Workup for heart and lung transplant

Use the codes describing a right heart catheterization (e.g., 93451) only for medically necessary diagnostic procedures. Do not report CPT® code 93503 in conjunction with other diagnostic cardiac catheterization codes. Code 93503 includes:

• Anesthesia (e.g., sedation)
• Insertion of the flow-directed catheter
• Recording of intracardiac and intravascular pressures
• Obtaining blood samples
• Using data obtained from catheter measurements

Endomyocardial Biopsy

93505   Endomyocardial biopsy

The physician threads a catheter into the heart through a central line to obtain small samples of heart muscle. Typically, multiple samples are obtained. Endomyocardial biopsy may be performed for the following indications:

• Tuberculosis of the heart
• Infective, isolated, or other acute myocarditis
• Eosinophilic endomyocardial disease
• Endocardial fibroelastosis
• Cardiomyopathies (e.g., dilated cardiomyopathy)
• Heart transplant failure, infection, rejection
• Cardiac allograft vasculopathy
• Heart-lung transplant complication or rejection

When this service is coded, list one unit of service, regardless of whether single or multiple biopsy excisions were performed.

Intravascular Ultrasound and Optical Coherence Tomography

92978   Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) 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)

Intravascular ultrasound (IVUS) is a diagnostic procedure in which a transducer on the tip of a coronary catheter is threaded through the coronary arteries and, using high-frequency sound waves, produces high-resolution cross-sectional images of the coronary arteries. Physicians use IVUS in preparation for, during, and to review the results of angioplasty or atherectomy. It is also used in the placement of stents.

Optical coherence tomography (OCT) is the use of near-infrared light to create detailed images of the inside of the coronary arteries. According to Texas Heart Institute:

A beam of light is directed at the artery, and some of the light reflects from inside the artery tissue, and some of it scatters. This scattered light causes something called ‘glare.’ Using OCT, the glare can be filtered out. Even the smallest amount of reflected light that is not scattered can be detected and used to form the image of the coronary artery. In fact, OCT allows cardiologists to see the inside of an artery in 10 times more detail than if they were using intravascular ultrasound.

Fractional Flow Reserve

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)

Fractional flow reserve (FFR) is a technique used in cardiac catheterization to measure pressure differences across a coronary artery stenosis. FFR measurement involves determining the ratio between the maximum achievable blood flow in a diseased coronary artery and the theoretical maximum flow in a normal coronary artery to determine the likelihood that the stenosis impedes oxygen delivery to the heart muscle.

Coding tip: When billing CPT® codes 92978, 92979, 93571, and 93572, use the appropriate coronary artery modifier to identify which vessel the procedure is being performed on. Coronary artery modifiers include:

• RC: Right coronary artery
• LC: Left circumflex coronary artery
• LD: Left anterior descending coronary artery
• LM: Left main coronary artery
• RI: Ramus intermedius

Pharmacologic Agent Administration

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)

CPT® code 93463 is reported in addition to the appropriate catheterization code when a pharmacologic agent — nitric oxide, nitroprusside, dobutamine, milrinone — is administered. This code includes the assessment of hemodynamic measurements before, during, and after administration, as well as for repeat pharmacologic agent administration. Report 93463 only once per left or right heart cath procedure.

Physiologic Exercise Study

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)

In this procedure, the physician subjects the patient to exercise and measures the effect on the heart through the assessment of various hemodynamic parameters, such as cardiac output, blood flow, blood pressure, and oxygen saturation, before and after the exercise.

Congenital Heart Disease Catheterization Codes

For 2022 five new codes for cardiac catheterization for congenital defects (93593-93597) replace codes 93530-93533, which are deleted. These codes are located in a new subsection of the CPT® code book with detailed introductory language and are for reporting procedures done on patients with normal native and abnormal native connections. This section also includes a new add-on code for cardiac output measurements.

93593   Right heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone; normal native connections

93594   Right heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone; abnormal native connections

93595   Left heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone, normal or abnormal native connections

93596   Right and left heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone(s); normal native connections

93597   Right and left heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone(s); abnormal native connections

+93598  Cardiac output measurement(s), thermodilution or other indicator dilution method, performed during cardiac catheterization for the evaluation of congenital heart defects (List separately in addition to code for primary procedure)

Clinicians and coders should review the new introductory language in the cardiac catheterization section to understand these changes. Per CPT® guidelines, catheterization for anomalous coronary arteries, patent foramen ovale, mitral valve prolapse, and bicuspid aortic valve should be reported with the non-congenital catheterization codes.

Having a solid understanding of the components of cardiac catheterization and the nuances involved in reporting these procedures will facilitate accurate coding and ensure proper reimbursement.

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Resources:

Bourassa, MG. “The History of Cardiac Catheterization.” 2006.
www.medscape.com.

Manda, Yugandhar, and Krishna Baradhi. “Cardiac Catheterization Risks and Complications.” PubMed, 2022. https://pubmed.ncbi.nlm.nih.gov.

Codify Features, Aug. 18, 2021. www.aapc.com/codify/features.aspx.

Billing and Coding Guidelines LCD Database. ID Number L33557. “Cardiac Catheterization and Coronary Angiography.” Contractor’s Determination. Number CV-006 Coding Information Revision, effective date Jan. 1, 2022.

Bourantas, C., Naka, K., Garg, S., Thackray, S., Papadopoulos, D., Alamgir, F., Hoye, A., Michalis, L. “Clinical Indications for Intravascular Ultrasound Imaging.” PubMed, 2010. www.ncbi.nlm.nih.gov/pubmed.

Center, Cedars-Sinai. “Intravascular Ultrasound IVUS.” 2022.
www.cedars-sinai.org/locations/cedars-sinai-main-campus-89.html.

Optical Coherence Tomography. www.texasheart.org/heart-health/heart-information-center/topics/optical-coherence-tomography.