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.