Cardiology Coding Alert

Tip: Think twice before using these codes -- CPT may offer a more comprehensive choice.

Mastering the dozens of new codes and pages of new guidelines CPT 2011 introduced for cardiology is no easy task. So to help ease the chore, here is a code-by-code breakdown for 93451 to 93453, covering the services included in each code, as well as a briefing on when not to assign these codes on your claim.

Start here: The codes in focus are:

• 93451 -- Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed
• 93452 -- Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed
• 93453 -- Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed.

Tip: If you need to reacquaint yourself with the guidelines that apply across the board to 93451- 93453 -- including separately reportable services and included services -- read "Part 1: 93451-93453: See How Guidelines Affect New Cardiac Cath Codes" in Cardiology Coding Alert, vol. 14, no. 4.

RHC: 93451 Applies to a Narrow Group

Code 93451 approximately replaces 2010 code 93501 (Right heart catheterization). But before you choose new code 93451, you need to be sure you understand when it applies and the many cases when another code would be more appropriate.

RHC defined: According to CPT guidelines, RHC includes cath placement in the right-sided cardiac chambers or structures. This includes the right atrium (RA), right ventricle (RV), pulmonary artery (PA), and wedge locations, advised David B. Dunn, MD, FACS, CIRCC, CPC-H, CCC, CCS, RCC, of ZHealth Publishing at TCI's Dec 2010 coding and reimbursement update conference.

CPT 2011 guidelines indicate RHC also includes taking blood samples to measure blood gases and measuring cardiac output if the physician performs them. This may include oxygen saturations, wedge pressures, and thermodilution studies, Dunn noted.

Tip from the field: Coders who had pre-2011 RHC claims reviewed note that auditors wanted to see all right heart chambers and structures documented to support the RHC code. That means that if the physician can't enter one of the structures or chambers, he should brieflyexplain why to make documentation complete.

Beyond 93451: CPT includes an instruction under 93451 telling you not to report the code with 93453 (combined right and left heart cath) or with 93456, 93457, 93460, or 93461 (which all include RHC in addition to other services). Another time you should steer clear of reporting 93451 is if the RHC is for a congenital case. Then you should report 93530 (Right heart catheterization, for congenital cardiac anomalies) instead of 93451, Dunn advised.

Bonus tips: You should not report 93503 (Insertion and placement of flow directed catheter [e.g., Swan- Ganz] for monitoring purposes) with 93451 or any other diagnostic cardiac cath codes, CPT guidelines instruct.

The guidelines also tell you not to append modifier 51 (Multiple procedures) to 93451.

And take extra care not to swap your digits if you type in the code manually, warned the presentation by Kenneth P. Brin, MD, PhD, FACC, CPT editorial panel member, and James Blankenship, MD, FACC, FSCAI, relative value update committee member, at the AMA's CPT and RBRVS 2011 Annual Symposium.

If your brain is running on automatic, you may accidentally report your old favorite code 93541 (Injection procedure during cardiac catheterization; for pulmonary angiography) when you mean to report new code 93451. Because 93541 has been deleted for 2011, reporting that code will bring an instant denial.

LHC: 93452 Covers Ventriculography, Too

If the cardiologist catheterizes only left heart structures, you'll need to consider whether 93452 is appropriate for your left heart catheterization (LHC) case. Code 93452 roughly covers the same services you would have coded in 2010 using 93510 (Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery, percutaneous), 93543 (Injection procedure during cardiac catheterization; for selective left ventricular or left atrial angiography), and 93555 (Imaging supervision, interpretation and report for injection procedure[s] during cardiac catheterization; ventricular and or atrial angiography).

LHC defined: The key indicator for LHC is that the physician crossed the aortic valve. CPT guidelines state, "Left heart catheterization involves catheter placement in a left-sided (systemic) cardiac chamber(s) (left ventricle or left atrium) and includes left ventricular injection(s) when performed." It also includes taking left ventricular pressures.

That means left ventriculography injection, supervision, interpretation and report are all included when performed, explained the Brin and Blankenship presentation, citing the guidelines. As a result, you should not report +93565 (Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective left ventricular or left atrial angiography ...) in addition to 93452.

Report separately: Although CPT includes multiple services in 93452, there are some services you may report separately. In some cases, the cardiologist may perform LHC using a transapical puncture of the left ventricle or a transseptal puncture when the septum is intact. CPT guidelines instruct that in that case, in addition to the appropriate LHC code, such as 93452, you should report +93462 (Left heart catheterization by transseptal puncture through intact septum or by transapical puncture [List separately in addition to code for primary procedure]).

More comprehensive options: Be sure to watch for cases where a code that's more comprehensive than 93452 is appropriate. In particular, CPT instructs you not to report 93452 with 93453 (RHC and LHC) or 93458-93461 (Catheter placement in coronary artery[s] for coronary angiography, including intraprocedural injection[s] for coronary angiography, imaging supervision and interpretation ...), which specify that they include LHC along with coronary angiography and other services.

Combo: 93453 Brings 93451 and 93452 Together

The services 93453 describes would essentially have been covered by 93526 (Combined right heart catheterization and retrograde left heart catheterization), 93543 (injection procedure), and 93555 (imaging S&I) in 2010. Because the procedure involves LHC, remember that the key identifier for that procedure is that the physician crossed the aortic valve.

Code 93453 involves both RHC and LHC, so once you understand when 93451 is appropriate for an RHC service and 93452 is appropriate for an LHC service, you're well on your way to mastering when to use 93453. Many of the same rules apply, as do many of the same restrictions.

Add-on do and don't: Just as with 93452 (LHC), you may report +93462 in addition to 93453 "when left heart catheterization is performed using either transapical puncture of the left ventricle or transseptal puncture of an intact septum," according to CPT guidelines.

Another instruction 93452 and 93453 share is not to report +93565 separately for ventriculography.

'Comprehensive' caution: As you well know by now, you have to be alert for codes that combine multiple services under a single code -- rather than reporting codes for the individual components -- when appropriate for the encounter.

For instance, CPT warns you not to report 93451 (RHC) or 93452 (LHC) alongside 93453, as those services are components of 93453. Similarly, you should not report 93453 alongside 93456-93461 because those codes include either an RHC, LHC, or both, plus coronary angiography and sometimes other services.

Congenital coding: You also need to stay alert for congenital cases. If the combined cath is for a congenital case, you should look to 93531-93533 (Combined ... for congenital cardiac anomalies) instead of 93453, Dunn pointed out.