The 2011 edition of the CPT® manual has dramatically streamlined the codes for cardiac catheterization.  Instead of assigning five codes for a basic left heart catheterization, cardiology coders now need only one.  But although the new system is much simpler in some respects, it still has its challenges.  In this article we'll show you how to navigate this new landscape.

CHD or Non-CHD?
There are still two separate sets of heart catheterization codesone for procedures performed for congenital heart disease (CHD), and one for everything else.  But it's now a little easier to decide which set of codes to use, because the CPT® manual tells you to use the non-CHD codes for patients who have certain minor heart defects.  Specifically, you should assign one of the non-CHD codes if the patient's only defect is anomalous coronary arteries, a patent foramen ovale, mitral valve prolapse, or bicuspid aortic valve.  (An example of anomalous coronary arteries would be a patient whose left anterior descending and left circumflex arise directly from the aorta instead of from the left main coronary artery.)  Studies on patients with these conditions are not significantly more work than those on patients with normal hearts.

Non-CHD Code Selection
Table 1 [see end of article] gives you a quick reference guide to the new codes for non-CHD heart catheterization.  The first step in selecting one of these codes is determining whether the physician catheterized the patient's native coronary arteries.  If the coronaries were catheterized, you should select a code from code series 93454-93461.  This series contains codes for coronary artery catheterization in combination with other procedures, such as bypass graft catheterization, left heart catheterization, and right heart catheterization.  You should assign only one of these codes regardless of how many structures were catheterized.  For example, if the physician catheterized the native coronary arteries and the left heart, you should assign only code 93458, which includes both procedures.

Several of the codes in the coronary catheterization series include catheterization of bypass grafts.  These codes are used when the physician catheterizes either arterial or venous bypass grafts.  You should also use them when the physician catheterizes an ungrafted internal mammary artery (IMA) to determine whether it can be used as a bypass conduit.  For example, if the physician catheterizes the native coronary arteries, one venous bypass graft, and the IMA, you should report one unit of code 93455, which includes all of these vessels.

There are combination codes for catheterization of the native coronaries and the left heart (left atrium and/or left ventricle).  For example, if the physician catheterizes the native coronaries, one or more bypass grafts, and the left ventricle, you should assign code 93459.  Just as in the past, the physician does not have to perform a left ventriculogram in order to report a code for left heart catheterization.  Just passing a catheter into the left ventricle or left atrium is enough.

Finally, there are combination codes for catheterization of the right heart in combination with coronary artery catheterization.  These codes include catheter placement in the right atrium and/or right ventricle and/or pulmonary arteries.

If the physician did not catheterize the coronary arteries, you have only three catheterization codes to choose from.  There is one code for right heart catheterization (93451), one for left heart catheterization (93452), and one for combined right and left heart catheterization (93453).

Angiography
The non-CHD heart catheterization codes include the angiograms that are typically performed with each specific type of catheterization.  For example, all of the codes for coronary artery catheterization (93454-93461) include contrast injection and imaging of the coronary arteries.  Likewise, all of the codes for bypass graft catheterization (93455, 93457, 93459, and 93461) include contrast injection and imaging of bypass grafts.  Finally, all of the left heart catheterization codes (93452-93453 and 93458-93461) include contrast injections and imaging of the left ventricle.

For example, if the physician catheterizes the coronary arteries and the left heart and performs coronary angiograms and a left ventriculogram, you should assign only code 93458.  This code includes both the coronary angiograms and the left ventriculogram.

You can still assign separate codes for right ventricular or right atrial angiography (93566), supravalvular aortography (93567), and pulmonary angiography (93568).  These codes include both the contrast injection and the imaging S&I.  For example, if the physician performs coronary artery catheterization, left heart catheterization, and a supravalvular aortogram, you should assign 93458 for the catheterization and 93567 for the aortogram.  Remember that code 93458 also includes the coronary angiograms and left ventriculogram, if performed.

A supravalvular aortogram is an imaging study of the portion of the aorta that is closest to the heart.  You should not use code 93567 for imaging studies of the descending thoracic aorta or the abdominal aorta.  Those studies should be reported with codes from the Radiology chapter of CPT®, or with HCPCS codes, depending on the payor's requirements.
 
Transseptal Puncture
Sometimes the cardiologist will access the left heart by puncturing the interatrial septum and passing a catheter from the right atrium into the left atrium.  In the past there were combination codes that included both the heart catheterization and the septal puncture.  For 2011, however, there is an add-on code for the septal puncture that you must assign in addition to the left heart catheterization code. 

The puncture is reported with code 93462 [Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (List separately in addition to code for primary procedure)].  You can assign this code together with any of the non-CHD left heart catheterization codes.  For example, you should assign 93462 together with 93452 for transseptal left heart catheterization that does not include coronary artery catheterization or right heart evaluation.

Notice that code 93462 requires puncture of an intact septum.  You cannot use this code when the physician simply passes the catheter through a pre-existing opening in the septum.  For example, if the physician performs transseptal left heart catheterization by passing the catheter through a patent foramen ovale, you would assign only code 93452 for the left heart catheterization.

You can also use code 93462 for left heart catheterization by transapical puncture.  This rarely-performed procedure involves passing a needle through the chest wall into the apex of the left ventricle, followed by a catheter. 

CHD Procedures
The CHD catheterization codes (93530-93533) have not changed for 2011.  Code 93532 still includes puncture of an intact interatrial septum, so you should not assign new code 93462 for the septal puncture.

The CHD codes do not include angiography.  You should assign separate codes for any documented contrast injections of the coronary arteries (93563), bypass grafts (93564), left ventricle or atrium (93565), right ventricle or atrium (93566), supravalvular aorta (93567), or pulmonary artery (93568).  For example, if the physician performs right heart catheterization for CHD with a pulmonary angiogram, you should assign codes 93530 and 93568.

Pharmacologic Challenge Tests
A challenge test (also referred to as a provocation test) is the evaluation of a patient's response to a drug or other substance. The test can help to confirm the patient's diagnosis or to guide his treatment. Cardiologists often perform challenge tests during cardiac catheterization, particularly when the patient is suspected to have pulmonary hypertension.  Agents commonly used for pharmacologic challenge tests include inhaled nitric oxide gas and intravenous nitroprussside, adenosine, dobutamine, etc. 

During an acute vasodilator challenge test for pulmonary hypertension, the physician performs a right heart catheterization to measure the patient's pulmonary artery pressures. Then, with the pulmonary artery catheter still in place, the cardiologist gives the patient strong but short-acting drugs that cause the arteries to expand.  If the patient's pulmonary artery pressure drops significantly, then the patient will most likely respond to treatment with calcium channel blockers.

Challenge tests during cardiac catheterization are reported with add-on code +93463 [Pharmacologic agent administration (eg, inhaled nitric oxide, intravenous infusion of nitroprusside, dobutamine, milrinone, or other agent), including assessing hemodynamic measurements before, during, after, and repeat pharmacologic agent administration, when performed (List separately in addition to code for primary procedure)].

Code 93463 is reported only once regardless of how many substances the physician administers.  It can be reported together with any of the non-CHD or CHD cardiac catheterization codes with the exception of 93454-93455 (coronary artery/bypass graft catheterization without right or left heart catheterization).  It does not require modifier 26 for professional component billing.

For example, a physician performs right heart catheterization on a patient with pulmonary hypertension, then administers intravenous adenosine while monitoring the patient's pressures.  The right heart catheterization is reported with 93451 and the adenosine challenge test is reported with 93463.

Exercise Tests
Cardiologists can perform exercise tests during cardiac catheterization to evaluate how the patient responds to increased oxygen demand.  This type of testing is often performed during right heart catheterization in patients with suspected pulmonary hypertension or valve disease.  With a catheter in place in the right heart, the physician monitors the patient's pulmonary artery pressure, pulmonary capillary wedge pressure (PCWP), and other parameters while the patient uses an exercise bicycle or an arm ergometer, which allows the patient to pedal with his arms instead of his legs.

Exercise studies during heart catheterization are reported with add-on code +93464 [Physiologic exercise study (eg, bicycle or arm ergometry) including assessing hemodynamic measurements before and after (List separately in addition to code for primary procedure)].

Code 93464 can be reported together with any of the non-CHD or CHD cardiac catheterization codes with the exception of 93454-93455 (coronary artery/bypass graft catheterization without right or left heart catheterization).  It is reported only once per catheterization procedure.  If you are billing only for the professional component, you must apply modifier 26 to code 93464.

For example, a cardiologist performs right heart catheterization, then has the patient ride an exercise bicycle with the Swan-Ganz catheter in place in the pulmonary artery.  You should assign 93451 for the right heart catheterization and 93464 for the exercise test.

Closure Devices
The CPT® manual lists some specific services that are included in the cardiac catheterization codes.  You cannot code separately for these services regardless of how well the physician documents them.  There are a few additions to this list for 2011.  In particular, the heart cath codes now specifically include angiograms of the access site that the physician takes in order to determine whether he can place a closure device (AngioSeal, Perclose, etc.).  For example, if the physician injects contrast into the femoral artery to see how close the puncture site is to the femoral bifurcation, you should not assign a femoral angiogram code like 75710 or G0278, since this service is a component of the heart catheterization. 

Additionally, placement of the closure device is now included in the heart cath codes.  You should not assign code G0269 [Placement of occlusive device into either a venous or arterial access site, post surgical or interventional procedure (e.g. angioseal plug, vascular plug)] for this service.

Conclusion
The new cardiac catheterization codes have been challenging for providers, but they have posed even more of a challenge for payors, since coverage policies and claims edits have had to be extensively reworked.  If you code and bill for these services, be sure to check your reimittances carefully to make certain you are being paid correctly, particularly during the first few months the new codes are in effect. 

It is also a good idea to do regular internal audits on your claims to make certain that they are being coded accurately.  In particular, if you work for a cardiology practice and the physicians do their own coding, make certain that they understand the guidelines.  You may need to do several sessions of one-on-one training to get each physician up to speed.

Jackie Miller, RHIA, CCS-P, CPC, PCS, is Vice President of Product Development for Coding Strategies, Inc. (www.codingstrategies.com), which offers coding reference manuals, newsletters, and online education for radiology, cardiology, oncology, and other specialties.  Both physician practice coders and hospital outpatient coders rely on Coding StrategiesSM products for quality information and ease of use.