**Abstract:**  
Cardiac catheterization is the introduction and positioning of a catheter in
the heart to assess cardiac function and structure, for diagnosis, treatment
planning or to assess therapy. This assessment may include the measurement of
intracardiac and intra- vascular 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 and interpreted 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
diagnostic procedures including coronary and bypass angiography, angiography
of the cardiac chambers, aortic and 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 generally includes hemodynamic
measurements, and cardiac output determination, and may also include, when
medically indicated, shunt determinations, and/or blood sampling, and/or
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 anticipated to require valvular surgical repair;  
9\. Suspected rejection of a transplanted heart;  
10\. Suspected pericardial tamponade or constriction.  
  
 **General Limitations:**  
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.  
  
 **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 reimbursement for a right heart catheterization performed in
conjunction with electrophysiologic tests or interventions, HIS bundle
studies, pacing studies, temporary pacemaker insertion, pulmonary angiography,
endomyocardial biopsy or interventional cardiac procedures, when **routinely
performed** for reasons other than a hemodynamic evaluation. Right heart
catheterization with hemodynamic measurements done at the same time as these
other procedures must be medically necessary based upon the underlying
cardiovascular pathophysiology. 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, electrophysiologic studies or other interventional
procedures.  
  
 **_Left Heart Catheterization_**  
 **Indications and Limitations for Left Heart Catheterization**  
This is the introduction of a catheter(s) into the left ventricle (LV). The
catheter may be inserted retrograde from the brachial, axillary or femoral
artery; by cutdown or percutaneously; or transseptally via a patent foramen
ovale or by septal puncture; or transapically. 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 **and the supervision and interpretation of such
services are reimbursable as part of all-inclusive codes for these services
(see Supplementary Instructions Article).**  
  
There is no additional reimbursement for a left heart catheterization done for
reasons other than hemodynamic evaluation or LV angiography **required for
patient management** (i.e., when **routinely** 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.  
  
 **_Left Heart Catheterization by Transseptal Puncture_**  
A catheter with an enclosed transseptal puncture needle is positioned into the
right atrium, and under fluoroscopic and/or ultrasonic guidance is advanced,
puncturing an intact intra-atrial septum thereby entering the left atrium. The
needle is then removed, leaving the catheter through which a guide wire may be
advanced to facilitate placement of appropriate catheters into the left atrium
and left ventricle. This procedure should not be billed if the catheter is
advanced into the left atrium through a patent foramen ovale or atrial septal
defect.  
  
The transseptal catheterization may be indicated in those cases in which
access to the left ventricle is required for hemodynamic measurements or
angiography, when retrograde access is not feasible or appropriate; when
access to the left atrium and pulmonary veins is necessary for hemodynamic
measurements and angiography; and when access to the left atrium and ventricle
is necessary for the performance of diagnostic and therapeutic
electrophysiological procedures.  
  
**_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 (including tumors and clots), 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.  
  
The injection procedure for supravalvular angiography for evaluation of an
ascending aortic aneurysm, performed during cardiac catheterization, may be
covered if it is medically necessary based on the presence of signs/symptoms
related to an ascending aneurysm or other imaging tests, when providing
additional diagnostic information. It is not separately payable when performed
with a thoracic aortogram.  
  
Coronary angiography is a single procedure which includes arteriograms of all
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. 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 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 suspected 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 non-coronary cardiac surgical
procedures (e.g., aortic or mitral valve surgery when not requiring left heart
catheterization). 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. Only intracoronary ultrasound or functional flow reserve
measurement should be performed on an individual artery, so that both services
performed on the same artery will not be reimbursed.  
  
 **_Pharmacologic Agent Administration With Hemodynamic Assessment_**  
The administration of pharmacologic agents to assess hemodynamic effects is
covered and separately reimbursable when performed as diagnostic test or to
assess the potential therapeutic interventions. All such interventions must
include pre-, intra- and post-infusion measurement of ventricular function
(e.g., ejection fraction or wall motion) or hemodynamics (changes in
intracardiac pressures, pulmonary artery pressures, or shunts ratios). Drug
administration to affect coronary angiography or to treat acute symptoms or
adverse events occurring during the catheterization such as acute ischemia or
coronary artery spasm, congestion (e.g., intravenous diuretics), arrhythmias
(e.g., beta-blockers, calcium channel blockers, digitalis, antiarrhythmic
drugs, etc) are not included in this code.  
  
**_Physiologic Exercise Study with Hemodynamic Measurement_**  
The performance of physiologic exercise to assess hemodynamic effects is
covered and separately reimbursable when performed as a diagnostic test to
evaluate cardiac abnormalities such as valve dysfunction, ventricular
dysfunction or shunt ratios. All such interventions must include pre-, intra-
and post-exercise measurement of ventricular function (e.g., ejection fraction
or wall motion) or hemodynamics.  
  
**_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 in a separate LCD
"Percutaneous Coronary Intervention". These are separately reimbursable
procedures.  
  
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.  
  
**_Teaching Physician_**  
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 Devices_**  
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_ the 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.
Angiography to assess the site of arterial access at the completion of the
procedures or to assess for vascular closure is included in the
catheterization procedure and is not separately reimbursable. Extra-cardiac
angiographic services must be specifically requested (and documented in the
patient's medical record) by the treating (referring) 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\. Assistant at surgery;  
2\. Right heart catheterization solely for the purpose of inserting a
temporary pacemaker, performing endomyocardial biopsy or performing
electrophysiologic studies;  
3\. Standby anesthesia or surgeon during angioplasty.  
  
 _**Services and Procedures Included in Cardiac Catheterization Procedures.**_  
1\. Prophylactic insertion of temporary transvenous pacemaker;  
2\. Repositioning and replacement of catheters;  
3\. Administration of medications during catheterization;  
4\. Insertion or use of percutaneous vascular closure devices;  
5\. 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.