October 16, 2006

Coding for Cardiac Catheterization
For The Record
Vol. 18 No. 21 P. 37

Cardiac catheterization is a procedure to determine whether there is blockage in the coronary arteries, the presence and severity of valvular heart disease, and/or septal wall defects.

The following are some AHA Coding Clinic for ICD-9-CM codes that may be assigned for a cardiac catheterization procedure depending on what procedure was performed:

• 37.21, Right heart cardiac catheterization;

• 37.22, Left heart cardiac catheterization;

• 37.23, Combined right and left heart cardiac catheterization;

• 88.52, Angiocardiography of right heart structures;

• 88.53, Angiocardiography of left heart structures;

• 88.54, Combined right and left heart angiocardiography;

• 88.55, Coronary arteriography using a single catheter;

• 88.56, Coronary arteriography using two catheters;

• 88.57, Other and unspecified coronary arteriography; and

• 88.58, Negative-contrast cardiac roentgenography.

Right Heart Catheterization
Right heart cardiac catheterization (37.21) includes studying the right atrium and ventricle, the tricuspid and pulmonary valves, the main pulmonary artery and its branches, and the superior and inferior vena cava (AHA Coding Clinic for ICD-9-CM, 1987, May/June, pages 11-12). A right heart catheterization involves inserting a catheter (sometimes a Swan-Ganz catheter) into the femoral vein. The catheterization report will include measurements for intracardiac pressure, pressure pulse tracing, and blood oxygen saturations, as well as calculation of cardiac output and vascular resistance.

Note, however, that the only way to determine cardiac output is with a Swan-Ganz catheter. A standard right-heart diagnostic cardiac catheter—like those used in the catheterization lab—won’t be able to perform this function. Dye does not have to be injected for it to be considered a right heart catheterization. The designation of “right heart catheterization” occurs because the right heart and/or venous system is accessed for detailed analysis.

Do not use code 37.21 with code 89.63, Pulmonary artery pressure monitoring or code 89.64, Pulmonary artery wedge monitoring unless a diagnostic cardiac catheterization was performed during the episode of care and a written report of the diagnostic catheterization is on file in the medical record. Therefore, if the purpose of the catheterization is the Swan-Ganz for pulmonary artery pressure or wedge monitoring only, then do not report code 37.21 as it would be considered just the approach (AHA Coding Clinic for ICD-9-CM 1985, Jan/Feb, page 7).

Left Heart Catheterization
A left heart cardiac catheterization (37.22) includes the study of the left atrium and ventricle, the mitral and aortic valves, the ascending left aorta, and possibly the pulmonary veins (AHA Coding Clinic for ICD-9-CM, 1987, May/June, pages 11-12). According to AHA Coding Clinic for ICD-9-CM, “the passage of a catheter into or through the chambers of the heart does not by itself constitute a diagnostic cardiac catheterization.” In addition, a cardiac catheterization procedure is not only done for the testing of internal pressure measurements and ventricular function. If the physician documents that a left heart catheterization was performed, the coder should assign a code for the procedure. If the coder is unable to determine what procedure was performed, the physician should be queried for clarification (AHA Coding Clinic for ICD-9-CM, 2005, second quarter, pages 10-11).

During a left heart catheterization, the physician will usually inject a bolus of contrast dye directly into the left ventricle (LV) to observe how well it is pumping. This bolus can be given via manual hand injection by the physician or with a mechanical dye injector set up to deliver a set amount of contrast over a set amount of time. Assessing LV pumping effectiveness in this manner is considered an arteriogram from a clinical perspective. Assessing LV function in this manner is a standard part of a left heart catheterization. Additional code(s) should be assigned for the left ventricular arteriogram performed during a heart catheterization. The code assignment will depend on the specific procedure done.

Coronary Angiography
It has often been asked whether a code for angiography may be assigned when it is done with an angioplasty. Is an angiography inherent to the procedure or should it be coded separately? Physicians will reinject dye to confirm lesion location prior to the angioplasty and/or stent. This is inherent to the procedure and may be called guiding shots and therefore not coded as an additional procedure.

However, it is possible that the physician may choose to do a full coronary angiography series/left heart catheterization prior to beginning the intervention. It depends on how much time has elapsed between the initial cardiac catheterization and the current percutaneous transluminal coronary angioplasty (PTCA)/stent procedure. The coder will need to determine the intent of the procedure. If it was the physician’s intent to perform another diagnostic left heart catheterization/coronary angiography, then it can be coded. However, if it was done only to confirm the lesion location, then it is considered inherent to the PTCA/stent and should not be coded. You can ask yourself the following questions in determining this factor:

• How long ago was the initial cardiac catheterization performed?

• Where was the cardiac catheterization performed—the same facility, a partnering facility, or a transferring facility with no affiliation to your hospital?

You may need to query the cardiologist for clarification prior to code assignment.

Coding and sequencing for cardiac catheterization are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, and Beth Bumgarner, RN, MS, CPUR, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payors as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.

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