Billing and Coding: Cardiac Catheterization and Coronary Angiography

This article contains coding and other guidelines that complement the local coverage determination (LCD) for Cardiac Catheterization and Coronary Angiography.

Coding Guidelines:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient’s condition for which the service was performed.

Specific coding guidelines:
Diagnosis Coding
A primary diagnosis of ICD-10-CM code Z09 (encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm); and a secondary diagnosis of ICD-10-CM code Z94.1 (heart transplant status); should be used for patients post-heart transplant requiring follow-up cardiac catheterization and not showing evidence of rejection.

Add the ICD-10-CM code for the underlying disorder (cause) for ICD-10-CM codes I25.82 (chronic total occlusion of coronary artery) and I31.4 (cardiac tamponade).

The CPT code(s) for the cardiac catheterization procedure(s), coronary angiography, and injection procedure(s) should be linked to the appropriate ICD-10-CM diagnosis code(s) that describes the indication for the procedure on the claim.

Modifier Guidelines
When billing for CPT codes 92978, 92979, 93571 and 93572, use the coronary artery modifier to identify which vessel is undergoing a specific procedure. The modifiers are RC: right coronary artery, LC: left circumflex coronary artery, LD: left anterior descending coronary artery, LM: left main coronary artery, and RI: ramus intermedius.

Claims for these services billed without the major artery modifier will be returned to the provider as unprocessable.

Coronary angiography procedures, performed during a therapeutic coronary artery procedure, that are integral parts of the procedure (e.g., guiding arteriograms), are considered to be part of the percutaneous coronary intervention and not separately reportable diagnostic procedures. However, when billing for a diagnostic cardiac catheterization or angiography, which has not been previously performed, but now is performed on the same day as a separate procedure prior to percutaneous coronary intervention, then the 59 modifier should be appended to the codes 93454 – 93461 as appropriate.

Not Separately Billable Services
The following services are included in cardiac catheterization and coronary angiography, and should not be separately billed to Medicare:

• sedation;
• local anesthesia;
• positioning, repositioning, and removal of catheter(s);
• recording of intravascular and intracardiac pressures;
• obtaining blood samples for blood gas determinations;
• cardiac output measurements at rest, or at rest and during exercise, with or without electrode catheter placement;
• monitoring services, such as ECG and arterial oxygen saturation;
• final evaluation;
• written report;
• administration of medications during catheterization to treat acute symptoms or adverse events (e.g., angina, congestion, arrhythmias, etc);
• post-procedure evaluation.

Medicare Part B covers only the professional component of cardiac catheterization and coronary angiography procedures, when they are performed in hospital inpatient and outpatient facility settings. The technical component is covered under the Part A benefit. Diagnostic cardiac catheterization performed in an office setting (where permitted) is covered under Part B for both the professional and technical components.

CPT and Units of Service 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 (93451-93464 and 93566-93568).

Use CPT code 93541 or other appropriate right heart catheterization code (93453, 93456, 93457, 93460 or 93461) when right heart catheterization is done in a cardiac catheterization laboratory or in an interventional radiology laboratory and the procedure is done as part of a formal cardiac catheterization study.

The CPT codes for right heart catheterization are to be reported only when they pertain to diagnostic studies. Therefore, they should not be separately coded when a flow-directed catheter (e.g., Swan-Ganz) is placed in the right heart for monitoring purposes or when an endomyocardial biopsy is performed without obtaining hemodynamic data not previously available.

When an endomyocardial biopsy (CPT code 93505) is performed during cardiac catheterization, bill only one unit of service regardless of the number of biopsies taken.

CPT codes 93454 and 93455 (catheter placement, angiography) should be billed, as appropriate, when coronary or bypass angiography without left heart catheterization is performed. CPT codes 93454 and 93455 may be billed only once per catheterization.

CPT codes for Cardiac Catheterization include all dye injections for angiography, catheter insertion/replacement and repositioning, and the supervision and interpretation. Component services are no longer separately billable. Codes may be billed once per catheterization encounter.

CPT code 93598 may not be billed with catheterization codes.

When a catheterization involving multiple components is performed, the single CPT code including all of the components should be billed. Services for the individual component parts may not be billed. CPT codes 93563-93565 may only be billed with CPT codes 93593, 93594, 93595, 93596, and 93597. Codes for right atrial/ventricular angiography, supravalvular aortography and pulmonary angiography may be billed as add-on codes with any of the catheterization codes.

The transeptal/transapical left heart catheterization (93462) may be billed with 93452-93453, 93458-93461, 93595, 93596 and 93597. This code may only be billed when there is a puncture of an intact septum and should not be billed if the catheter is advanced into the left atrium through a patent foramen ovale or atrial septal defect.

Pharmacologic agent administration (93463) and Physiologic exercise study (93464) may only be coded when performed with pre-, intra- and post-intervention hemodynamic and function measures as a diagnostic test or to evaluate potential therapeutic interventions.

Percutaneous insertion of an intra-aortic balloon catheter may be coded separately when performed during the same encounter that cardiac catheterization or coronary angiography is performed.

The CPT codes for repair of blood vessel, direct (35201, 35206 and 35226) and repair of blood vessel with graft other than vein (35261, 35266 and 35286) are codes for open repairs of these vessels, and should not be used to bill for the use of percutaneous vascular closure devices (G0269) with angiographic, cardiac catheterization and interventional cardiology or radiology procedures.

Selective extra-cardiac angiography performed during cardiac catheterization, when medically necessary, should be billed using the appropriate codes from the 36140-36254 and 75625-75716 series. These codes should also be billed when these angiographic services are performed unrelated to cardiac catheterization.

Codes from 36140 through 36254 and 75625 through 75716 should only be coded if they are used to code selective studies and were medically necessary for diagnostic purposes as described in the LCD.

For claims submitted to the Part B MAC:

All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.

The insertion of the percutaneous closure device (G0269) is a bundled service and not separately billable by the physician.

The name and NPI of the treating physician who specifically requested/ordered extra-cardiac angiographic services must be submitted in items 17 and 17a of the CMS 1500 form or in the electronic equivalent of the claim for these services.

Supervision Criteria
The global and technical component [TC] procedures are covered under part B when performed under personal physician supervision (the physician would have to be present in the room while the entire cardiac catheterization is being performed) in the following circumstances:

• The procedure is performed in an IDTF or free-standing facility;
• The cardiac catheterization is performed in an entity set up as a physician office or physician directed clinic;

The professional components (-26) and professional services are reimbursable in any approved site of service when performed under personal physician supervision (the physician would have to be present in the room while the entire cardiac catheterization is being performed).

For claims submitted to the Part A MAC:

Cardiac catheterizations for which an overnight stay is anticipated, for routine recovery, should not be billed as inpatient services. Furthermore, the routine recovery period should not be billed as observation hours in addition to the catheterization unless the patient has sustained untoward complications necessitating the continued monitoring. An inpatient or observation stay following a routine outpatient cardiac catheterization would be considered not medically necessary and denied.

The insertion of the percutaneous closure device (G0269) is not a reimbursable service although it should be billed on the UB-92 claim but as a non-reimbursable supply (“N”status).

Documentation Requirements:

Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be returned.

The patient’s medical record should contain documentation that fully supports the medical necessity for cardiac catheterization and coronary angiography as it is covered by Medicare. This documentation includes, but is not limited to, relevant medical history, physical examination and results of pertinent diagnostic tests or procedures.

The medical record should contain a formal procedure report and interpretation for each procedure performed.

The record must include documentation of the medical decision making when interventional procedures are not performed during the same session as the diagnostic procedures.

The medical record must include documentation of the medical necessity for each procedure when multiple catheterization and angiographic procedures are performed during the same session.

The medical record must include an interpretation and report of all angiograms. Imaging for each angiographic procedure (film, video or digital) must be retained in the medical record and be available for review by the Medicare contractor.

The medical record must include documentation of request for extra-cardiac angiography from the referring/ordering provider treating the patient.

Medical records must be made available to Medicare upon request.

Utilization Guidelines:

Diagnostic coronary angiography may not be billed when performed during percutaneous coronary intervention, if it has been previously performed within the past six months resulting in the decision for the beneficiary to undergo the specific interventional procedure.