**Abstract:**  
Cardiac catheterization is the introduction and positioning of a catheter into
the heart to assess cardiac function and structure, for diagnosis, treatment
planning or to monitor therapy. This assessment may include the measurement of
intracardiac and intra-arterial pressures, obtaining blood samples for blood
gas or other constituent analysis, determination of cardiac output, injection
of contrast for angiography, and performing endomyocardial biopsy. The conduct
and evaluation of these procedures are then documented by the physician, in a
report.  
  
Cardiac catheterization may be utilized in various clinical situations ranging
from those requiring only a right heart catheterization to those requiring the
performance of right and left heart catheterization with simultaneous
interventional procedures including coronary and bypass angiography,
angiography of the cardiac chambers, pulmonary angiography, endomyocardial
biopsy, and extra-cardiac angiography. The guidelines in this policy outline
the indications for coverage of each procedure.  
  
 **Indications:**  
 _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. Right heart catheterization is a formal diagnostic procedure (with
report) performed in a catheterization or other procedure suite, as compared
to Swan-Ganz catheterization which is generally performed for ongoing
monitoring of the patient (after the initial diagnostic results are recorded),
performed at the bedside, or in an operating room, emergency department or
other intensive/critical care unit. The results of the Swan-Ganz
catheterization may be recorded in the progress notes rather than by a formal
report.  
  
Right heart catheterization, performed along with left heart catheterization,
coronary angiography, or both, is seldom medically reasonable and necessary
unless one disease process appears to affect both sides of the heart, or a
different disease process appears to affect each side of the heart.  
  
 **Indications for Right Heart Catheterization**  
Right heart catheterization is indicated to evaluate:  
1\. Valvular heart disease;  
2\. Congestive heart failure;  
3\. Congenital heart disease;  
4\. Cor pulmonale;  
5\. Pulmonary hypertension;  
6\. Intracardiac shunts (including septal rupture) and extracardiac vascular
shunts;  
7\. Suspected cardiomyopathy or myocarditis;  
8\. Endocarditis requiring valvular surgical repair;  
9\. Suspected rejection of a transplanted heart;  
10\. Suspected pericardial tamponade or constriction.  
  
 **Limitations for Right Heart Catheterization**  
This procedure is performed in a cardiac catheterization laboratory or
interventional radiology laboratory, and does not include "bedside placement"
of a flow directed (Swan-Ganz type) catheter.  
  
There is no additional reimbursement for a right heart catheterization
performed in conjunction with electrophysiologic tests or interventions, HIS
bundle studies, pacing studies, temporary pacemaker insertion, endomyocardial
biopsy or interventional cardiac procedures, when done for reasons other than
a hemodynamic evaluation. Right heart catheterization with hemodynamic
measurements done at the same time as these other procedures must still meet
the requirements of medical necessity. Right heart catheterization for the
purpose of monitoring hemodynamic status during an electrophysiologic or other
interventional cardiac procedure or angioplasty is included in that procedure
and is not separately reimbursable.  
  
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:  
1\. Atherosclerotic heart disease without heart failure; or  
2\. Angioplasty or other interventional procedures  
  
 **_Swan-Ganz Catheterization_**  
This procedure commonly includes insertion of a flexible, balloon-tipped
catheter into the pulmonary artery for bedside diagnosis or hemodynamic
monitoring of the critically ill patient. This procedure includes cannulation
of a central vein, such as the subclavian or internal jugular vein, through
which a flow-directed catheter is advanced into the right atrium (RA), right
ventricle (RV), and pulmonary artery (PA). The catheter may be "wedged"
briefly into a small pulmonary artery branch for estimation of the left atrial
filling pressure. Direct pressure measurements are obtained in each chamber,
the pulmonary artery and wedge, and recorded. In addition, other hemodynamic
parameters such as the cardiac output, systemic vascular resistance (SVR),
mixed venous oxygen saturation, and intrapulmonary shunt fraction may be
measured and are included in the procedure. Swan-Ganz catheterization includes
the insertion of a central venous line when performed via the same introducer
or catheter.  
  
 **Indications for Swan-Ganz Catheterization**  
Swan-Ganz catheterization may be indicated in the following situations:  
1\. Acute myocardial infarction with hemodynamic instability or septal
rupture;  
2\. Severe hypotension of unknown etiology, especially if the response to
initial therapy is inadequate (e.g., volume loading);  
3\. Selected cases of septic shock;  
4\. Adult respiratory distress syndrome, to confirm the diagnosis of non-
cardiogenic pulmonary edema (normal "wedge" pressure) and to aid in subsequent
fluid and ventilator management;  
5\. Suspected cases of cardiac tamponade, to confirm the diagnosis, monitor
hemodynamics during pericardiocentesis, and follow response to therapy;  
6\. Suspected papillary muscle rupture;  
7\. Congestive heart failure responding poorly to diuretics, especially when
intravascular volume status is uncertain;  
8\. Intraoperative monitoring of patients undergoing open heart surgery,
abdominal aortic aneurysm repair, or non-cardiac surgery in high-risk patients
with known severe cardiac conditions;  
9\. Drug overdose, especially when the risk of acute lung damage is high
(e.g., heroin, aspirin);  
10\. Exacerbations of chronic obstructive lung disease requiring intubation;
when it is anticipated that hemodynamic monitoring may detect occult or
superimposed causes of respiratory failure not suspected clinically (e.g.,
left ventricular dysfunction);  
11\. End-stage liver failure with deteriorating renal function;  
12\. Suspected cases of pulmonary hypertension.  
  
In general, Swan-Ganz catheterization is indicated when measurement of right
atrial, pulmonary artery, and pulmonary artery wedge 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 performed in conjunction
with electrophysiologic tests or intervention, HIS bundle studies, pacing
studies, temporary pacemaker insertion, interventional cardiac procedures or
angioplasty, and endomyocardial biopsy catheterization done for reasons other
than hemodynamic evaluation. Swan-Ganz catheterization with hemodynamic
measurements done at the same time as these other procedures will still have
to meet the same requirements of medical necessity. Swan-Ganz catheterization
for the purpose of monitoring hemodynamic status during an electrophysiologic
or other interventional cardiac procedure or angioplasty is included in that
procedure and is not separately reimbursable.  
  
There is no additional reimbursement to leave a catheter in place for
monitoring at the conclusion of Swan-Ganz catheterization, or for its
subsequent removal. Subsequent hemodynamic measurements (including the
inflation of the catheter tip balloon) and blood sampling are not reimbursable
under Part B as these functions may be performed by technicians and nurses in
a hospital setting and do not require the skill of a physician. Repositioning
of an existing catheter is not separately reimbursable and is included in an
evaluation and management code.  
  
 **Swan-Ganz catheterization is not indicated for:**  
1\. Atherosclerotic heart disease without heart failure; or  
2\. Angioplasty or other interventional procedures.  
  
 **_Left Heart Catheterization_**  
 **Indications and Limitations for Left Heart Catheterization**  
This is the introduction of catheter(s) into left ventricle (LV). The catheter
may be inserted retrograde from the brachial, axillary or femoral artery; by
cutdown or percutaneously; or transseptal via a patent foramen ovale or by
septal puncture. The catheterization also includes catheterization of the left
atrium and aorta when performed with the LV catheterization. It includes all
hemodynamic measurements (with and without maneuvers and/or infusions or
medication), 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 cardiac chambers or structures, arteries and conduits are separately
reimbursable.  
  
There is no additional reimbursement for a left heart catheterization done for
reasons other than hemodynamic evaluation or LV angiography (i.e., when
performed with coronary/bypass angiography, electrophysiologic or pacing
studies, or endomyocardial biopsies).  
  
Left heart catheterization is indicated for the diagnosis of, or treatment
planning in patients with myocardial abnormalities or dysfunction (including
ischemic disease, myocarditis, cardiomyopathy, etc), valvular dysfunction,
intracardiac shunts, congenital heart abnormalities, cardiac trauma, or
pericardial tamponade.  
  
 **_Cardiac Angiography_**  
**Indications and Limitations for Angiography**  
Angiograms of the individual cardiac chambers (atria and ventricles) are
indicated for the assessment of mitral or tricuspid valve function,
ventricular function or morphology, suspected ventricular aneurysms,
intracardiac shunts, congenital heart disease and cardiac trauma. Each
procedure (atrial or ventricular angiography) may be reimbursed only once
regardless of the number of injections of contrast, views or actual pictures
taken.  
  
Aortography is reimbursable only for diagnoses of aortic root and ascending
aorta 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 is billed as a single procedure and includes arteriograms
of all the coronary arteries and their branches, regardless of the number of
vessels selectively catheterized or visualized, with and without the
administration of diagnostic or therapeutic vasoactive medications. The
procedure may be reimbursed only once regardless of the number of contrast
injections, views or 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.
Arterial conduit and venous bypass graft angiography are separately reimbursed
using the same criteria as are used for the native coronary circulation
(reimbursed only once regardless of the number of contrast injections, views
or films, or whether medications were administered).  
  
Coronary and bypass angiography are indicated for the diagnosis of, or
treatment planning, for patients with anginal syndromes, atypical chest pain
syndrome suggesting ischemia, congenital heart disease, following cardiac
arrest thought to be due to ischemia or infarction, myocardial infarction,
known atherosclerotic or other coronary disease, suspected graft or stent/PTCA
closure, Prinzmetal's angina, coronary shunts and fistulae, cardiac trauma and
for treatment planning in patients undergoing cardiac surgical procedures. It
is also indicated for treatment planning in high-risk patients with evidence
of ischemic heart disease undergoing high-risk non-cardiac surgical procedures
(arterial or aortic surgery, or surgery with large fluid shifts).  
  
**_Pulmonary Angiography_**  
 **Indications for Pulmonary Angiography**  
Indications for pulmonary angiography include suspected pulmonary emboli,
pulmonary hypertension, pulmonary A-V malformations or shunts, pulmonary
artery stenosis, and congenital heart disease affecting the pulmonary
vasculature or pulmonary vasculature or pulmonary venous return.  
  
 **_Intra-Coronary Ultrasound and Doppler Functional Flow Reserve Studies_  
Indications for Intracoronary ultrasound and Doppler functional flow reserve
studies**  
Intracoronary ultrasound may be separately covered when needed to assess the
extent of coronary stenosis if equivocal on angiography, or when needed to
assess the patency and integrity of a coronary artery post-intervention.
Alternatively, intravascular Doppler velocity and/or pressure derived coronary
flow reserve measurement may be performed to assess the degree of stenosis
within a vessel.  
  
**_Angioplasty/Stent Placement/Atherectomy_**  
 **Indications and Limitations for Angioplasty/Stent Placement/Atherectomy**  
  
Diagnostic cardiac catheterization with coronary angiography is separately
reimbursable when performed prior to an interventional procedure. It may be
performed 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. Additionally, when the diagnostic and interventional
procedures are performed on the same day, multiple surgery pricing will be
applied. Angiography **before,** during, **or** after an interventional
procedure to evaluate results or to guide the catheter(s) is considered
incidental to the procedure and not separately reimbursable.  
  
Performance of a diagnostic cardiac catheterization and interventional
procedure on the same day is increasingly the standard of practice. While
there may be reasons for delaying the interventional procedure (e.g., transfer
from a community hospital to a tertiary center, excessive dye load, further
treatment planning or evaluation of angiography, etc.), it is recommended that
both procedures be performed during the same encounter when medically
appropriate. Separation of these procedures for the purpose of circumventing
the multiple surgery pricing, or for the convenience of physician or hospital
scheduling, could be considered an inappropriate practice and subject the
services to review and denial for medical necessity. Reasons for delaying
indicated intervention should be documented in the medical record.  
  
Cardiac catheterization requires personal ("at the elbow") supervision of its
performance by a physician. When performed in a teaching setting, the teaching
physician must be present, in the room, with the resident, throughout the
_**entire**_ procedure. The performance of these services by the resident
alone would not establish a basis for Medicare payment and will be denied as
not medically necessary.  
  
Vascular closure (with or without an implantable device or other mechanical
intervention) of the puncture site is an inherent part of all procedures for
arterial access. 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 (e.g., injection of the abdominal aorta, carotid,
ileofemoral or renal arteries) is sometimes performed during the same session
with cardiac catheterization.  
  
These procedures are generally not indicated during cardiac catheterization
and will be denied unless there are specific medical conditions that would
have been appropriate to require angiography independent of cardiac
catheterization being performed during the same encounter (i.e., these extra-
cardiac angiograms would have been performed at this point in the patient's
medical course even if cardiac catheterization had not been performed). The
determination of medical necessity will require that there are _reasonably
anticipated_ therapeutic implications for which these angiograms will be used.
These extra-cardiac angiographic services must be specifically requested (and
documented in the patient's medical record) by the treating physician. Extra-
cardiac angiography performed during an encounter other than with cardiac
catheterization is not subject to the indications and limitations of this LCD.  
  
Dye injection during catheterization or angiographic procedures for the
purpose of guiding the catheter placement is an integral part of the
procedures and is not separately reimbursable.  
  
 **_Other Non-covered Procedures During Catheterization_**  
  
1\. Prophylactic insertion of temporary transvenous pacemaker;  
  
2\. Assistant at surgery;  
  
3\. Right heart catheterization solely for the purpose of inserting a
temporary pacemaker, performing endomyocardial biopsy or performing
electrophysiologic studies;  
  
4\. Standby anesthesia or surgeon during angioplasty;  
  
5\. Repositioning and replacement of catheters;  
  
6\. Administration of medications during catheterization;  
  
7\. Insertion or use of percutaneous vascular closure devices;  
  
8\. Anesthesia;  
  
 **_Training Requirements_**  
The American College of Cardiology (ACC) and the American Heart Association
(AHA) have issued joint guidelines on training in cardiac catheterization and
interventional cardiology. Providers who submit claims for diagnostic
catheterization services must have a minimum of Level 2 training as outlined
by the ACC/AHA Task Force 3. Submission of claims will be viewed as an
attestation that the provider has met these requirements.