Heart / Cardiac Catheterization Coding Left/Right

Right Heart Catheterization
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.
Indications for Right Heart Catheterization

Right heart catheterization is indicated to evaluate:
· Valvular heart disease
· Congestive heart failure
· Congenital heart disease
· Cor pulmonale
· Pulmonary hypertension
· Intracardiac shunts
Limitations for Right Heart Catheterization

This procedure is done in a cardiac catheterization laboratory or interventional radiology laboratory, and does not include a "bedside placement" of a flow directed (Swan-Ganz type) catheter.
There is no additional reimbursement for a right heart catheterization done for reasons other than hemodynamic evaluation. Studies done in conjunction with electrophysiologic tests, HIS bundle studies, pacing studies, temporary pacemaker insertion and endomyocardial biopsy are not separately payable. Right heart catheterization with hemodynamic measurements done at the same time as these above-mentioned procedures will still have to meet the requirements of medical necessity.
There is no additional reimbursement for leaving a catheter in place for monitoring at the conclusion of a right heart catheterization or for the introduction of a Swan-Ganz type catheter at the time of a right heart catheterization, or for its subsequent removal.
Right heart catheterization is not indicated for:

· Atherosclerotic heart disease without heart failure
· Angioplasty or other interventional procedures
Swan-Ganz Catheterization
This procedure commonly includes insertion of a flexible, balloon-tipped catheter into the pulmonary artery for hemodynamic monitoring of the critically ill patient. Although Swan-Ganz catheterization is considered an invasive procedure, it may be safely performed at the bedside in an intensive care unit setting, using continuous EKG and blood pressure monitoring. In brief, this technique involves cannulation of a large vein, such as the subclavian or internal jugular vein. A flow-directed catheter is advanced through the central venous system into the right atrium (RA), right ventricle (RV), and pulmonary artery (PA). If desired, the catheter may be further "wedged" briefly into a small pulmonary artery branch. Direct pressure measurements are obtained in the respective cardiac chambers and pulmonary artery. An indirect measurement of left atrial filling pressure is obtained when the catheter is "wedged". In addition, other hemodynamic parameters may be easily measured, such as the cardiac output, systemic vascular resistance (SVR), mixed venous oxygen saturation, and intrapulmonary shunt fraction.
Indications for Swan-Ganz Catheterization
Swan-Ganz catheterization is indicated in the following situations:
· Acute myocardial infarction with hemodynamic instability
· Severe hypotension of unknown etiology, especially if the response to initial therapy is inadequate (e.g., volume loading)
· Selected cases of septic shock
· Adult respiratory distress syndrome, to confirm the diagnosis of noncardiogenic pulmonary edema (normal "wedge" pressure) and to aid in subsequent fluid and ventilator management
· Suspected cases of cardiac tamponade, to confirm the diagnosis, monitor hemodynamics during pericardiocentesis, and follow response to therapy
· Suspected papillary muscle rupture
· Possible ventricular septal defect or atrial septal defect following myocardial infarction
· Congestive heart failure responding poorly to diuretics, especially when intravascular volume status is uncertain
· Intraoperative monitoring of patients undergoing open heart surgery, particularly coronary artery bypass procedures involving multiple vessels; patients undergoing abdominal aortic aneurysm repair may also benefit from PA catheterization perioperatively
· Drug overdose, especially when the risk of acute lung damage is high (e.g., heroin, aspirin)
· Exacerbations of chronic obstructive lung disease requiring intubation; hemodynamic monitoring may detect occult or superimposed causes of respiratory failure not suspected clinically (e.g., left ventricular dysfunction)
· End-stage liver failure with deteriorating renal function
· Suspected cases of pulmonary hypertension
· Intraoperative and hemodynamic perioperative monitoring of patients with significant heart disease, undergoing non-cardiac surgery
In general, Swan-Ganz catheterization is indicated when measurement of right atrial, pulmonary artery, and pulmonary artery occlusive pressures will significantly alter patient management.
Limitations for Swan-Ganz Catheterization
This procedure is done at the bedside in the critical care unit or the operating room.
There is no additional reimbursement for a Swan-Ganz catheterization done for reasons other than hemodynamic evaluation. Studies done in conjunction with electrophysiologic tests, HIS bundle studies, pacing studies, temporary pacemaker insertion and endomyocardial biopsy are not separately payable. Swan-Ganz catheterization with hemodynamic measurements done at the same time as these above-mentioned procedures will still have to meet the requirements of medical necessity.
There is no additional reimbursement to leave a catheter in place for monitoring at the conclusion of Swan-Ganz catheterization.
Swan-Ganz catheterization is not indicated for:
· Atherosclerotic heart disease without heart failure
· Angioplasty or other interventional procedures

Left Heart Catheterization
Indications and Limitations for Left Heart Catheterization
This is the introduction of catheter(s) into the aorta, left ventricle and left atrium and includes cannulation of the coronary arteries and bypass grafts. It includes hemodynamic measurements, blood sampling and shunt determinations as part of the procedure. Placement of multiple catheters and their repositioning or replacement is included in this procedure. Injection procedures for selective opacification of arteries and conduits are separately reimbursable.
There is no additional reimbursement for a left heart catheterization done for reasons other than hemodynamic evaluation or angiography. Therefore, left heart catheterization is not separately reimbursed with studies such as electrophysiologic or pacing studies, or endomyocardial biopsies (unless there is medical necessity).
Angiography
Indications and Limitations for Angiography
Angiograms of the individual cardiac chambers will be reimbursed based on medical necessity. Coding must utilize the most all-inclusive procedure description. Each procedure may be reimbursed only once regardless of the number of views or actual pictures taken.
Aortography is reimbursable only for diagnoses of aortic root disease, valvular heart disease or congenital heart disease. It is not reimbursable for atherosclerotic heart disease. Angiograms to visualize the coronary ostia are included as part of coronary angiography. A diagnosis of "rule out (valvular lesion)" is not reimbursable.
Coronary angiography includes arteriograms of all the coronary arteries and their branches, regardless of the number of vessels visualized. Coronary angiography includes angiograms done with the administration of medications for diagnostic purposes (e.g., ergonovine, nitroglycerine) as part of the procedure. The procedure may be reimbursed only once regardless of the number of views, films or whether medications were administered. Replacement and repositioning of catheters are considered as part of the procedure, and are not reimbursable separately. The selective injection procedures may be performed without a formal left heart catheterization.

Angioplasty/Stent Placement/Atherectomy
Indications and Limitations for Angioplasty/Stent Placement/Atherectomy
The interventional procedures - percutaneous transluminal angioplasty, coronary stent placement and atherectomy are described under the interventional cardiology policy. These are separately reimbursable procedures.
Diagnostic cardiac catheterization with coronary angiography performed prior to an interventional procedure is reimbursable whether done on the same day or on a previous day, when used as a diagnostic tool to evaluate the need for the intervention, but only once prior to the interventional procedure. When the interventional procedure and cardiac catheterization with angiography are done on the same day, the multiple surgery pricing will apply (payment in full for the higher of two procedures and 50% for the second, etc.). Angiography to evaluate results of the interventional procedure and to guide the catheter(s) (to assist with the interventional procedure) is considered incident to the procedure and is not separately reimbursable.
General Limitations
The completion of the diagnostic cardiac catheterization and the interventional procedure on the same day is increasingly the standard of practice. While there may be legitimate reasons for delaying the interventional procedure (e.g., transfer from a community hospital to a tertiary center), Medicare strongly discourages the separation of these procedures to circumvent the multiple surgery pricing.
Cardiac catheterization requires personal (in person) supervision of its performance by a physician. When performed in a teaching setting, the teaching physician must be present with the resident throughout the procedure. The performance by the resident alone would not establish a basis for fee schedule payment for such services.
Vascular closure of the puncture site is an inherent part of all procedures for arterial access. As such, it is included in the arterial access codes for all angiographic and catheterization procedures, and may not be billed separately.
Extra Cardiac Angiography performed with Cardiac Catheterization.
Extra Cardiac Angiography is sometimes reported with cardiac catheterization. These services include interrogation of the abdominal plus iliofemoral artery, abdominal aorta, carotid and renal arteries.
However, such services are generally not indicated and will be denied unless there are specific conditions that warrant selective investigation. Examples of specific clinical syndromes are: subclavian steal syndrome, TIA (transient ischemic attack), renal artery stenosis, hypertensive patients with pulmonary edema and renal failure.
These extra angiographic services must be specifically requested by the treating physician.





Other Non-covered Procedures During Catheterization
· Prophylactic insertion of temporary transvenous pacemaker
· Assistant at surgery
· Right heart catheterization for the purpose of inserting a temporary pacemaker or performing electrophysiologic studies
· Standby anesthesia or surgeon during angioplasty
· Repositioning and replacement of catheters
· Administration of medications during catheterization
· Percutaneous vascular closure (e.g., Perclose)
· Anesthesia

**Please Check CPT guidelines before coding