Cardiology Coding Alert

Cardiac Procedures:

Take Your RHC and Endomyocardial Biopsy Savvy Up a Notch

Find out what the OIG is watching for this procedure pair.

Rules for coding an abbreviated right heart catheterization with endomyocardial biopsy got an update in the 2016 Correct Coding Initiative manual, as discussed in “2 CCI Manual Updates to Know Before You Code Your Next Cardiology Claim.”

Here’s a closer look at these procedures.

Biopsy: An endomyocardial biopsy involves using a catheter to enter the heart and take one or more samples of heart tissue, typically to check for signs of heart transplant rejection. The relevant code is 93505 (Endomyocardial biopsy).

RHC: CPT® guidelines state that “cardiac catheterization is a diagnostic medical procedure.”

“The CPT® 2016 definition of a right heart cath as well as the guideline remains unchanged in recent times — ‘Right heart catheterization includes catheter placement in one or more right-sided cardiac chamber(s) or structures (i.e., the right atrium, right ventricle, pulmonary artery, pulmonary wedge), obtaining blood samples for measurement of blood gases, and cardiac output measurements (Fick or other method), when performed,’” says Ray Cathey, PA, MHS, CMSCS, CHCI, president of Medical Management Dimensions in Stockton, Calif.

You also may find payer definitions. For example, MAC CGS Administrators includes this definition in its LCD L33959: “This is the introduction of a catheter(s) into the right atrium, right ventricle and pulmonary artery. It includes hemodynamic measurements, cardiac output determination, shunt determinations, blood sampling, and hydrogen arrival time as part of the procedure. Placement of catheter(s), repositioning, and replacement with other catheters are included as part of the procedure. Cannulation of the coronary sinus is included in this procedure.”

RHC + biopsy bundle: “Endomyocardial biopsy and right heart cath have been bundled for quite a few years now, unless there is a distinct, non-related reason to do both, such as a patient with a heart transplant follow-up in addition to pulmonary hypertension,” Cathey says.

And watching for that distinct, non-related reason, like pulmonary hypertension, is crucial. Other indications for an RHC include valvular heart disease, congestive heart failure, congenital heart disease, cor pulmonale, intracardiac shunts, endocarditis and myocarditis, cardiogenic shock, myocardial infarction, and transplanted valve.

But keep in mind that the cardiologist’s documentation should indicate the medical necessity for the diagnostic RHC at that session. Watch for RHCs documented as periodic, routine, elective, or for surveillance because those terms suggest the RHC was not diagnostic. Reporting RHCs that are not properly supported at the same session as biopsy is a common problem area.

Consequently, for hospitals, “the OIG is currently closely scrutinizing billing of endomyocardial biopsies and right heart caths at the same session,” Cathey says. Their wording in the 2016 OIG Work Plan states, “We will review Medicare payments for right heart catheterizations (RHC) and endomyocardial biopsies billed during the same operative session and determine whether hospitals/providers complied with Medicare billing requirements. Previous OIG reviews have identified inappropriate payments when hospitals/providers were paid for separate RHC procedures when the services were already included in payments for endomyocardial biopsies. To be processed correctly and promptly, a bill must be completed accurately. (CMS’s Medicare Claims Processing Manual, Pub. No. 100-04, ch. 1, §” The Work Plan is available at .

Bonus tip … RHC + LHC medical necessity: When the provider performs both left and right heart caths, she should be sure to document medical necessity for each. “The medical necessity of both procedures (right and left) must be documented in the cath report and the diagnoses submitted should reflect a separate diagnosis for performing each procedure. All too often we see that the 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] code is billed without a diagnosis code reflecting a reason for performing the right heart cath,” Cathey says. So keep in mind that you may need more than one diagnosis code to support performing both.