Cardiology Coding Unmasked - Part 1 Cardiac Catheterization, CPT Codes: 93451-93461 and Associated Codes, Coding Hints

April 24th, 2013 - Nancy Maguire


Cardiac catheterization (KATH-eh-ter-ih-ZA-shun) is a medical procedure used to diagnose and treat some heart conditions. Cardiac catheterization is a diagnostic medical procedure that includes: introduction of the catheter, positioning and repositioning of the catheter, recording of intracardiac or intravascular pressure(s), the final evaluation and report. Also, according to the American

College of Cardiology (ACC) and American Medical Association (AMA), CPT code 93503 cannot be reported with codes for diagnostic cardiac catheterization because recordings of intracardiac and intravascular pressures, blood sampling for measurement of oxygen saturation or blood gases, or cardiac output measurements are considered an integral component of those procedures.

A long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck and threaded to your heart. Through the catheter, diagnostic tests and treatments can be performed on the main arteries on heart. This is followed by an injection of a type of dye into the catheter. The dye will flow through the bloodstream to the patient’s heart. Then, x-ray pictures of the heart will make the coronary (heart) arteries visible on the pictures. This test is called coronary angiography (an-jee-OG-rah-fee).

The dye can show whether a waxy substance called plaque (plak) has built up inside your coronary arteries. Plaque can narrow or block the arteries and restrict blood flow to your heart. The buildup of plaque in the coronary arteries is called coronary heart disease (CHD) or coronary artery disease (CAD).

For all of the cardiac catheterization procedures, imaging supervision, interpretation, and report are included with the injection procedure, not reported separately.

Right heart catheterization includes, catheter placement in one or more right cardiac chamber(s), obtaining blood samples for blood gas measurement and cardiac output measurement. A right heart catheterization includes the insertion of a Swan-Ganz catheter. When coding a Swan-Ganz for monitoring purposes only use code 93503. When a Swan Ganz is inserted (usually at bedside) and left in for continuous monitoring (usually 48-72 hours), use 93503. But, when the catheter(s) is placed within the right heart structures (in the cath lab), to take pressures/measurements, and withdrawn when completed, use a right heart catheterization code. This code (93503) should not be used with any other right heart catheterization procedures. When coding a right heart catheterization with other procedures please make sure to read the CPT code very carefully. Make sure to use codes that have a right heart catheterization included in the code description (i.e. 93453, 93456, 93457, 93460 and 93461).

Left heart catheterization includes, vascular access, catheter placement in left-sided (systemic) cardiac chamber(s), sedation and monitoring, measurement of pressures, removal of catheters, left ventriculography (if performed), coronary angiography, closure device angiography, closure device deployment and report generation. The documentation should indicate crossing of the aortic valve and that the pressures are from inside the left heart chamber.

Right and Left Heart Catheterization CPT code 93461: Catheter placement in coronary artery(s) for coronary angiography, including intra-procedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placements(s) in bypass graft(s) (internal mammary, free arterial, venous graft(s) with bypass graft angiography. Code 93461 describes the routine right and left heart catheterization with the addition of imaging of bypass grafts.

CPT code 93460-26: Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intra-procedural injection(s) for left ventriculography, when performed. Code 93460 describes a routine right and left heart catheterization.

CPT code 93453-26: Combined right and left heart catheterization including intra-procedural injection (s) for left ventriculography, imaging supervision and interpretation, when performed. Code 93453 is another procedure code that will be utilized less commonly. It includes no injections and imaging other than of the left ventricle, when performed.

Catheterization W/O Left Heart: CPT code 93455-26- Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts) including intraprocedural injection(s) for bypass graft angiography. Code 93455 describes the imaging of only the native coronary arteries and bypass grafts. There is no longer any distinction between arterial and venous bypass grafts.

CPT code 93454-26: Catheter placement in coronary artery(s) for coronary angiography, including intra-procedural injection(s) for coronary angiography, imaging supervision and interpretation. Code 93454 is utilized when only native coronary angiography is performed. This is not a left heart catheterization as the left-sided chambers are not entered for pressure measurements.

CPT code 93456-26: Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization, without concomitant left heart catheterization.

CPT code 93457-26: Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization, (no left heart catheterization).

CPT code 93451-26 describes a right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed. Do not code this procedure with codes 93453, 93456, 93457, 93460 or 93461.

The Centers for Medicare & Medicaid Services (CMS) acknowledges three coronary vessels: left circumflex (LC), right coronary (RC), and left anterior descending (LD). However, other payers also may allow separate coding for interventions in the left main coronary artery (LMCA). In any case, you can code only one therapy within each of the main vessels and their branches. Example, if you perform an angioplasty and a coronary stent placement, only the coronary stent placement may be billed.

Modifier LC branches include: Left main, Circumflex and Obtuse marginal (1 and 2).
Modifier LD branches include: Left anterior descending, Diagonal (1 and 2), and Septal branches.
Modifier RC branches include: Right coronary artery, Posterior descending.

The coronary modifiers are appropriate to assign with the following procedure codes: Coronary Angioplasty, Atherectomy and Stent Procedures (CPT codes 92980, 92981, 92982, 92984, 92996).

Doctors also can use ultrasound (+92978, +92979, add-on codes) during cardiac catheterization to see blockages in the coronary arteries. Ultrasound uses sound waves to create detailed pictures of the heart's blood vessels. These add-on codes may only be assigned with specific CPT codes. Code +92978 may only be assigned with codes 92975 (Thrombolysis, coronary), 92980 (Transcatheter placement of an intracoronary stent(s), percutaneous), 92982 (Percutaneous transluminal coronary balloon angioplasty), 92995 (Percutaneous transluminal coronary atherectomy), 93454-93461 (Catheter placement for coronary angiography), 93530-93533 (Right heart catheterization for congenital cardiac anomalies).

Pharmacologic agent administration +93463 includes assessing hemodynamic measurements before, during, after, and repeat pharmacologic agent administration, when performed. This code is not to be reported for intracoronary administration of pharmacologic agents during percutaneous coronary interventional procedures 92975, 92977, 92980, 92982, and 92995. It may be reported only once per catheterization even if multiple agents are administered. Example, inhaled nitric oxide for pulmonary hypertension during heart catheterization to determine pulmonary vasoreactivity.

Add-on CPT codes: +93563 – +93568 have been established for right heart injection procedures, pulmonary angiography, and aortography for all catheterization patients; and for left heart injection, coronary angiography, and bypass graft angiography for patients with congenital heart disease (reported with 93530 – 93533).

CPT add-on code +92973 describes “mechanical fragmentation of the thrombus”, code 92973 should not be reported for aspiration of a thrombus. Thrombectomy by means of aspiration catheter is included in the intervention. Documentation must support reporting +92973, keep in mind that you should not report it as an individual code. It is an add-on code and should go with either 92980 (Transcatheter placement of an intracoronary stent[s], percutaneous, with or without other therapeutic intervention, any method; single vessel) or 92982 (Percutaneous transluminal coronary balloon angioplasty; single vessel).

Endometrial biopsy (93505) may be reported separately in addition to a cardiac catheterization code. But, if the cardiac catheterization is only performed as a means of obtaining the biopsy, and a separate diagnostic catheterization is not performed, then only the endomyocardial biopsy may be reported.

Common Cardio Abbreviations:

LIMA: left internal mammary artery
OM: obtuse marginal artery
ICA: intercranial/internal carotid artery
ECA: extracranial/external carotid artery
CCA: common carotid artery
SVC: superior vena cava
IVC: inferior vena cava
Review of Medical Cardiologist Super-bill:
  • Include all levels of E/M codes
  • Include Prolonged service codes
  • Include injection and infusion administration codes
  • Include injected medication codes (J codes)
  • Include vaccine codes frequently administered
  • Include cardiac procedures, therapeutic and diagnostic (include space for referring physician)
  • Includes lab services
  • Add modifier -26 where appropriate
  • Include preventive services and counseling (ex, smoking cessation)
  • If diagnosis codes are included make sure they are detailed and taken to highest level of specificity.
Part 2 of this series will discuss therapeutic procedures during cardiac catheterization.

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