Cardiac Catheterization CPT code - 93451, 93458, 93530 - 93568, covered DX

Procedure code and description


93458 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary

angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed $321 5.85


Diagnostic Catheterization

• Diagnostic left heart catheterization (ventriculography only): procedure code 93452

• Combined right and left heart catheterization (ventriculography only): procedurecode 93453

• Coronary Arteriogram (no ventriculography): procedure codes 93454, 93455

• Coronary Arteriogram and right catheterization (no ventriculography): procedurecodes 93456, 93457

• Coronary Arteriogram (with ventriculography): procedure codes 93458, 93459


• Coronary Arteriogram and right catheterization (with ventriculography): procedurecodes 93460, 93461

Diagnostic cardiac catheterization is the introduction and maneuvering of a catheter into the heart to assess cardiac function. This assessment may include the measurement of intracavitary pressures, obtaining blood samples for blood gas analysis, dilution curves and determination of cardiac output. Additionally, specific angiographic information may be obtained by selective injection of contrast material.

Cardiac catheterization is generally indicated to determine the optimal therapeutic strategy in a given patient with heart disease. It may also be used to establish that the diagnosis is coronary artery disease. In most cases, the results of diagnostic cardiac catheterization would guide the physician in selecting a primarily medical vs. an interventional or surgical approach.
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. The following guidelines outline the medical necessity for coverage.

Right Heart Catheterization
This is the introduction of a catheter(s) into the right atrium, right ventricle and pulmonary artery. Hemodynamic measurements, cardiac output determination, shunt determinations, blood sampling and hydrogen arrival time are commonly included 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.


Indications for Right Heart Catheterization
  • Right heart catheterization is indicated to evaluate:
    • Valvular heart disease.
    • Congestive heart failure.
    • Congenital heart disease.
    • Cor pulmonale.
    • Pulmonary hypertension.
    • Intracardiac shunts.
    • Endocarditis and Myocarditis.
    • Cardiogenic shock.
    • Myocardial infarction.
    • Transplanted heart or valve.

Limitations for Right Heart Catheterization
This procedure is done in a cardiac catheterization laboratory or interventional radiology laboratory and does not include a "bedside placement" of a flow directed (Swan-Ganz type) catheter.


  • Right heart catheterization is not indicated for:
    • Atherosclerotic heart disease without heart failure.
    • Angioplasty or other interventional procedures.

There is no additional reimbursement for a right heart catheterization done for reasons other than hemodynamic evaluation. Studies done in conjunction with electrophysiologic tests, HIS bundle studies, pacing studies, temporary pacemaker insertion and endomyocardial biopsy are not separately payable. Right heart catheterization with hemodynamic measurements done at the same time as these above-mentioned procedures will still have to meet the requirements of medical necessity.

Left Heart Catheterization


Indications and Limitations for Left Heart Catheterization


This is the introduction of catheter(s) into the aorta, left ventricle and left atrium and includes cannulation of the coronary arteries and bypass grafts. It includes hemodynamic measurements, 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 arteries and conduits are separately reimbursable.

There is no additional reimbursement for a left heart catheterization done for reasons other than hemodynamic evaluation or angiography. Therefore, left heart catheterization is not separately reimbursed with studies such as electrophysiologic or pacing studies or endomyocardial biopsies (unless there is medical necessity).

Angiography


Indications and Limitations for Angiography:


Angiograms of the individual cardiac chambers will be reimbursed based on medical necessity.
Aortography is reimbursable only for diagnoses of aortic root 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 includes arteriograms of all the coronary arteries and their branches, regardless of the number of vessels visualized. Coronary angiography includes angiograms done with the administration of medications for diagnostic purposes (e.g., ergonovine, nitroglycerin) as part of the procedure. The selective injection procedures may be performed without a formal left heart catheterization.



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 under the Interventional Cardiology LCD, 4C-54. These are separately reimbursable procedures. Diagnostic cardiac catheterization with coronary angiography performed prior to an interventional procedure is reimbursable whether done 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.

General Limitations

The completion of the diagnostic cardiac catheterization and the interventional procedure on the same day is increasingly the standard of practice. While there may be legitimate reasons for delaying the interventional procedure (e.g., transfer from a community hospital to a tertiary center), Medicare strongly discourages the separation of these procedures to circumvent the multiple surgery pricing.

Cardiac catheterization requires personal (in person) supervision of its performance by a physician. When performed in a teaching setting, the teaching physician must be present with the resident throughout the procedure. The performance by the resident alone would not establish a basis for fee schedule payment for such services.

Vascular closure of the puncture site is an inherent part of all procedures for arterial access. As such, it is included in the arterial access codes for all angiographic and catheterization procedures, and may not be billed separately. Percutaneous vascular closure devices (PVCD) are now available to close an arterial puncture site after angiography, cardiac catheterization and interventional cardiology procedures. These devices are used in place of manual compression, a mechanical clamp to apply pressure to the puncture site, a sandbag or a combination of these methods.

Several PVCDs have been approved by the FDA:
  • Techstar®XL.
  • Prostar®XL.
  • Prostar®Plus (Perclose, Inc).
  • Angio-Seal™ (Sherwood-Davis & Geck).
  • VasoSeal® (Datascope Corp.).
  • Any additional similar devices.
The advantages of these devices include more rapid hemostasis and earlier patient ambulation after the angiographic or cardiac procedure, allowing more of these procedures to be performed as outpatient services.

They also reduce the amount of physician time spent compressing an artery and monitoring a patient post-angiography or catheterization. These services are not separately payable with diagnostic cardiac catheterization procedures.


Other Non-covered Procedures During Catheterization:
  • Prophylactic insertion of temporary transvenous pacemaker.
  • Assistant at surgery.
  • Right heart catheterization for the purpose of inserting a temporary pacemaker or performing electrophysiologic studies.
  • Standby anesthesia or surgeon during angioplasty.
  • Repositioning and replacement of catheters.
  • Administration of medications during catheterization.
  • Percutaneous vascular closure (e.g., Perclose).
  • Anesthesia.

Cardiac catheterization is covered for payment by Medicare when performed in the inpatient hospital, outpatient hospital, and free-standing cardiac catheterization facilities that meet the Medicare provider enrollment requirements and are enrolled with Medicare as physician directed clinics.
Payments for Cardiac Catheterization Performed in Independent Diagnostic Testing Facilities (IDTF):
Independent Diagnostic Testing Facilities are eligible for Medicare payments for cardiac catheterization services subject to this LCD. All eligible IDTFs must be accredited for performing these procedures on or before January 1, 2008. Accepted accrediting organizations are:
  • Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
  • Accreditation Association for Ambulatory Health Care (AAAHC).

 Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.

Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 85X

Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.

93451©
Right heart catheterization - Fee schedule amount  $774.29
93452©
Left heart catheterization - Fee schedule amount  $879.09
93453©
Combined right and left heart catheterization
93454©
Catheter placement in coronary art for coronary angiography
93455©
Catheter placement in coronary art for coronary angiography
93456©
Catheter placement in coronary art for coronary angiography
93457©
Catheter placement in coronary art for coronary angiography
93458©
Catheter placement in coronary art for coronary angiography - Fee amount $1072.02
93459©
Catheter placement in coronary art for coronary angiography - $1184.99
93460©
Catheter placement in coronary art for coronary angiography Fee amount -$1272.18
93461©
Catheter placement in coronary art for coronary angiography - Fee amount - $1453.81
93462©
Left heart catheterization
93530©
Rt heart cath, congenital
93531©
R & l heart cath, congenital
93532©
R & l heart cath, congenital
93533©
R & l heart cath, congenital
93563©
Injection procedure during cardiac cath
93564©
Injection procedure during cardiac cath
93565©
Injection procedure during cardiac cath
93566©
Injection procedure during cardiac cath
93567©
Injection procedure during cardiac cath
93568©
Injection procedure during cardiac cath


Billing and Coding Guidelines

What cardiac procedures will require prior authorization?

A Prior authorization is required for the following procedurecodes: Diagnostic Catheterization

• procedurecodes: 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461 Electrophysiology Implants

• Pacemaker Implant procedurecodes: 33206, 33207, 33208, 33212, 33213, 33214, 33227, 33228

• CRT (Cardiac Resynchronization Therapy) proceduredevice codes: 33221, 33224, 33229, 33231, 33264, procedureLead 33225


• Defibrillator (AICD) Implant procedurecodes: 33230, 33240, 33249, 33262, 33263 

ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.


Right Heart and Combined Right and Left Heart Catheterization
Medicare is establishing the following limited coverage for CPT/HCPCS codes 93451 and 93453:

Covered for:
093.20–093.24
Syphilitic endocarditis
093.81–093.82
Other specified cardiovascular syphilis
093.89
Other specified cardiovascular syphilis
391.0–391.2
Rheumatic fever with heart involvement
391.8–391.9
Rheumatic fever with heart involvement
393
Chronic rheumatic pericarditis
394.0–394.2
Diseases of mitral valve
394.9
Other and unspecified mitral valve diseases
395.0–395.2
Diseases of aortic valve
395.9
Other and unspecified rheumatic aortic diseases
396.0–396.3
Diseases of mitral and aortic valve
396.8–396.9
Diseases of mitral and aortic valve
397.0–397.1
Diseases of other endocardial structures
397.9
Rheumatic diseases of endocardium valve unspecified
398.0
Rheumatic myocarditis
398.90–398.91
Other rheumatic heart disease
398.99
Other rheumatic heart diseases
402.01
Malignant hypertensive heart disease with heart failure
402.11
Benign hypertensive heart disease with heart failure
402.91
Unspecified hypertensive heart disease with heart failure
404.01
Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage i through stage iv, or unspecified
404.03
Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage v or end stage renal disease
404.11
Hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney disease stage i through stage iv, or unspecified
404.13
Hypertensive heart and chronic kidney disease, benign, with heart failure and chronic kidney disease stage v or end stage renal disease
404.91
Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage i through stage iv, or unspecified
404.93
Hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney disease stage v or end stage renal disease
410.00–410.02
Acute myocardial infarction of anterolateral wall
410.10–410.12
Acute myocardial infarction of other anterior wall
410.20–410.22
Acute myocardial infarction of inferolateral wall
410.30–410.32
Acute myocardial infarction of inferoposterior wall
410.40–410.42
Acute myocardial infarction of other inferior wall
410.50–410.52
Acute myocardial infarction of other lateral wall
410.60–410.62
True posterior wall infarction
410.70–410.72
Subendocardial infarction
410.80–410.82
Acute myocardial infarction of other specified sites
410.90–410.92
Acute myocardial infarction of unspecified site
415.0
Acute cor pulmonale
415.11
Iatrogenic pulmonary embolism and infarction
415.19
Other pulmonary embolism and infarction
416.0–416.2
Chronic pulmonary heart disease
416.8–416.9
Chronic pulmonary heart disease
417.0–417.1
Other diseases of pulmonary circulation
417.8–417.9
Other diseases of pulmonary circulation
420.0
Acute pericarditis in diseases classified elsewhere
420.90–420.91
Other and unspecified acute pericarditis
420.99
Other acute pericarditis
421.0–421.1
Acute and subacute endocarditis
421.9
Acute endocarditis unspecified
422.0
Acute myocarditis in diseases classified elsewhere
422.90–422.93
Other and unspecified acute myocarditis
422.99
Other acute myocarditis
423.0–423.2
Other diseases of pericardium
423.8–423.9
Other diseases of pericardium
424.0–424.3
Other diseases of endocardium
424.90–424.91
Endocarditis valve unspecified
424.99
Other endocarditis valve unspecified
425.0–425.5
Cardiomyopathy
425.7–425.9
Cardiomyopathy
427.1–427.2
Cardiac dysrhythmias
427.41–427.42
Ventricular fibrillation and flutter
427.5
Cardiac arrest
428.0–428.1
Heart failure
428.20–428.23
Systolic heart failure
428.30–428.33
Diastolic heart failure
428.40–428.43
Combined systolic and diastolic heart failure
428.9
Heart failure unspecified
429.0–429.6
Ill-defined descriptions and complications of heart disease
429.71
Certain sequelae of myocardial infarction not elsewhere classified acquired cardiac septal defect
429.81
Other disorders of papillary muscle
429.83
Takotsubo syndrome
745.0
Common truncus
745.10–745.12
Transposition of great vessels
745.19
Other transposition of great vessels
745.2–745.5
Bulbus cordis anomalies and anomalies of cardiac septal closure
745.60–745.61
Endocardial cushion defects
745.69
Other endocardial cushion defects
745.7–745.9
Bulbus cordis anomalies and anomalies of cardiac septal closure
746.00–746.02
Anomalies of pulmonary valve
746.09
Other anomalies of pulmonary valve
747.0
Patent ductus arteriosus
747.10–747.11
Coarctation of aorta
747.20–747.22
Other anomalies of aorta
747.29
Other anomalies of aorta
747.3
Anomalies of pulmonary artery
747.40–747.42
Anomalies of great veins
747.49
Other anomalies of great veins
785.51
Cardiogenic shock
794.30–794.31
Cardiovascular, nonspecific abnormal results of cardiovascular function studies
794.39
Other nonspecific abnormal results of function studies
996.02
Mechanical complication of heart valve prosthesis
996.74
Other complications due to other vascular device implant and graft
996.83
Complications of transplanted heart
V12.51
Personal history of venous thrombosis and embolism
V42.1
Heart replaced by transplant
V42.2
Heart valve replaced by transplant
V42.6
Lung replaced by transplant
V43.3
Heart valve replaced by other means
V58.44
Aftercare following organ transplant
Left Heart Catheterization
Medicare is establishing the following limited coverage for CPT/HCPCS codes 93452 and 93462:
Covered for:
394.0–394.2
Diseases of mitral valve
394.9
Other and unspecified mitral valve diseases
395.0–395.2
Diseases of aortic valve
395.9
Other and unspecified rheumatic aortic diseases
396.0–396.3
Diseases of mitral and aortic valve
396.8–396.9
Diseases of mitral and aortic valve
397.0–397.1
Diseases of other endocardial structures
397.9
Rheumatic diseases of endocardium valve unspecified
402.00–402.01
Malignant hypertensive heart disease
402.10–402.11
Benign hypertensive heart disease
402.90–402.91
Unspecified hypertensive heart disease
410.00–410.02
Acute myocardial infarction of anterolateral wall
410.10–410.12
Acute myocardial infarction of other anterior wall
410.20–410.22
Acute myocardial infarction of inferolateral wall
410.30–410.32
Acute myocardial infarction of inferoposterior wall
410.40–410.42
Acute myocardial infarction of other inferior wall
410.50–410.52
Acute myocardial infarction of other lateral wall
410.60–410.62
True posterior wall infarction
410.70–410.72
Subendocardial infarction
410.80–410.82
Acute myocardial infarction of other specified sites
410.90–410.92
Acute myocardial infarction of unspecified site
411.0–411.1
Other acute and subacute forms of ischemic heart disease
411.81
Acute coronary occlusion without myocardial infarction
411.89
Other acute and subacute forms of ischemic heart disease other
412
Old myocardial infarction
413.0–413.1
Angina pectoris
413.9
Other and unspecified angina pectoris
414.00–414.06
Coronary atherosclerosis
414.07
Coronary atherosclerosis of bypass graft (artery) (vein) of transplanted heart
414.10–414.11
Aneurysm and dissection of heart
414.19
Other aneurysm of heart
414.3
Coronary atherosclerosis due to lipid rich plaque
414.8–414.9
Other specified forms of chronic ischemic heart disease
420.0
Acute pericarditis in diseases classified elsewhere
420.90–420.91
Other and unspecified acute pericarditis
420.99
Other acute pericarditis
421.0–421.1
Acute and subacute endocarditis
421.9
Acute endocarditis unspecified
422.0
Acute myocarditis in diseases classified elsewhere
422.90–422.93
Other and unspecified acute myocarditis
422.99
Other acute myocarditis
423.0–423.2
Other diseases of pericardium
423.8–423.9
Other diseases of pericardium
424.0–424.3
Other diseases of endocardium
424.90–424.91
Endocarditis valve unspecified
424.99
Other endocarditis valve unspecified
425.0–425.5
Cardiomyopathy
425.7–425.9
Cardiomyopathy
426.7
Anomalous atrioventricular
427.0
Paroxysmal supraventricular
427.1–427.2
Cardiac dysrhythmias
427.31–427.32
Atrial fibrillation and flutter
427.41–427.42
Ventricular fibrillation and flutter
427.5
Cardiac arrest
427.89
Other specified cardiac dysrhythmias
428.0–428.1
Heart failure
428.20–428.23
Systolic heart failure
428.30–428.33
Diastolic heart failure
428.40–428.43
Combined systolic and diastolic heart failure
429.0–429.6
Ill-defined descriptions and complications of heart disease
429.71
Certain sequelae of myocardial infarction not elsewhere classified acquired cardiac septal defect
429.79
Certain sequelae of myocardial infarction not elsewhere classified other
429.81–429.83
Other ill-defined heart diseases
429.89
Other ill-defined heart diseases
786.05
Shortness of breath
786.09
Respiratory abnormality other
786.50–786.52
Chest pain
786.59
Other chest pain
793.2
Nonspecific (abnormal) findings on radiological and other examination of other intrathoracic organs
794.30–794.31
Cardiovascular, nonspecific abnormal results of function tests
794.39
Other nonspecific abnormal results of cardiovascular function tests
996.02–996.03
Mechanical complication of cardiac device implant and graft
996.09
Other mechanical complication of cardiac device implant and graft
996.61–996.62
Infection and inflammatory reaction due to internal prosthetic device implant and graft
996.71–996.72
Other complications of internal (biological) (synthetic) prosthetic device implant and graft
996.83
Complications of transplanted heart
997.1
Cardiac complications not elsewhere classified
V12.53
Personal history of sudden cardiac arrest icd9 update
V42.1
Heart replaced by transplant
V42.2
Heart valve replaced by transplant
V45.81
Postsurgical aortocoronary bypass status
V45.82
Percutaneous transluminal coronary angioplasty status
Coronary Arteriograms
Medicare is establishing the following limited coverage for CPT/HCPCS codes 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93565, 93566 and 93567:
Covered for:
394.0–394.2
Diseases of mitral valve
394.9
Other and unspecified mitral valve diseases
395.0–395.2
Diseases of aortic valve
395.9
Other and unspecified rheumatic aortic diseases
396.0–396.3
Diseases of mitral and aortic valve
396.8–396.9
Diseases of mitral and aortic valve
402.00–402.01
Malignant hypertensive heart disease
402.10–402.11
Benign hypertensive heart disease
402.90–402.91
Unspecified hypertensive heart disease
410.00–410.02
Acute myocardial infarction of anterolateral wall
410.10–410.12
Acute myocardial infarction of other anterior wall
410.20–410.22
Acute myocardial infarction of inferolateral wall
410.30–410.32
Acute myocardial infarction of inferoposterior wall
410.40–410.42
Acute myocardial infarction of other inferior wall
410.50–410.52
Acute myocardial infarction of other lateral wall
410.60–410.62
True posterior wall infarction
410.70–410.72
Subendocardial infarction
410.80–410.82
Acute myocardial infarction of other specified sites
410.90–410.92
Acute myocardial infarction of unspecified site
411.0–411.1
Other acute and subacute forms of ischemic heart disease
411.81
Acute coronary occlusion without myocardial infarction
411.89
Other acute and subacute forms of ischemic heart disease other
412
Old myocardial infarction
413.0–413.1
Angina pectoris
413.9
Other and unspecified angina pectoris
414.00–414.06
Coronary atherosclerosis
414.07
Coronary atherosclerosis of bypass graft (artery) (vein) of transplanted heart
414.10
Aneurysm of heart (wall)
414.3
Coronary atherosclerosis due to lipid rich plaque
414.8–414.9
Other specified forms of chronic ischemic heart disease
420.0
Acute pericarditis in diseases classified elsewhere
420.90–420.91
Other and unspecified acute pericarditis
420.99
Other acute pericarditis
424.0–424.2
Other diseases of endocardium
425.0–425.5
Cardiomyopathy
425.7–425.9
Cardiomyopathy
427.1–427.2
Cardiac dysrhythmias
427.31–427.32
Atrial fibrillation and flutter
427.41–427.42
Ventricular fibrillation and flutter
427.5
Cardiac arrest
427.89
Other specified cardiac dysrhythmias
428.0–428.1
Heart failure
428.20–428.23
Systolic heart failure
428.30–428.33
Diastolic heart failure
428.40–428.43
Combined systolic and diastolic heart failure
428.9
Heart failure unspecified
429.0–429.6
Ill-defined descriptions and complications of heart disease
429.71
Certain sequelae of myocardial infarction not elsewhere classified acquired cardiac septal defect
429.79
Certain sequelae of myocardial infarction not elsewhere classified other
429.83
Takotsubo syndrome
441.2
Thoracic aneurysm without rupture
674.50–674.54
Peripartum cardiomyopathy
745.0
Common truncus
745.10–745.12
Transposition of great vessels
745.19
Other transposition of great vessels
745.2–745.5
Bulbus cordis anomalies and anomalies of cardiac septal closure
745.60–745.61
Endocardial cushion defects
745.69
Other endocardial cushion defects
745.7–745.9
Bulbus cordis anomalies and anomalies of cardiac septal closure
746.85
Coronary artery anomaly congenital
786.02
Orthopnea
786.05
Shortness of breath
786.50–786.52
Chest pain
786.59
Other chest pain
793.2
Nonspecific (abnormal) findings on radiological and other examination of other intrathoracic organs
794.30–794.31
Cardiovascular, non-specific abnormal results of function tests
794.39
Other, non-specific abnormal results of cardiovascular function tests
861.01
Contusion of heart without open wound into thorax
996.02–996.03
Mechanical complication of cardiac device implant and graft
996.09
Other mechanical complication of cardiac device implant and graft
996.61–996.62
Infection and inflammatory reaction due to internal prosthetic device implant and graft
996.71–996.72
Other complications of internal (biological) (synthetic) prosthetic device implant and graft
996.83
Complications of transplanted heart
997.1
Cardiac complications not elsewhere classified
V12.53
Personal history of sudden cardiac arrest
V42.1
Heart replaced by transplant
V42.2
Heart valve replaced by transplant
V43.21
Heart replaced by heart assist device
V43.22
Heart replaced by fully implantable artificial heart
V58.44
Aftercare following organ transplant
V58.69
Long-term (current) use of other medications
V81.0*
Screening for ischemic heart disease
Note: *Code V81.0 for angiography to assess ischemic heart disease without a prior cardiac stress test along with an appropriate diagnosis of angina.
Cardiac Catheterization for Congenital Cardiac Anomalies
Medicare is establishing the following limited coverage for CPT/HCPCS codes 93530, 93531, 93532, 93533, 93563, 93564, 93565 and 93566:
Covered for:
745.0
Common truncus
745.10–745.12
Transposition of great vessels
745.19
Other transposition of great vessels
745.2–745.5
Bulbus cordis anomalies and anomalies of cardiac septal closure
745.60–745.61
Endocardial cushion defects
745.69
Other endocardial cushion defects
745.7–745.9
Bulbus cordis anomalies and anomalies of cardiac septal closure
746.00–746.02
Anomalies of pulmonary valve
746.09
Other congenital anomalies of pulmonary valve
746.1–746.7
Other congenital anomalies of heart
746.81–746.89
Other specified anomalies of heart
746.9
Unspecified anomaly of heart
747.0
Patent ductus arteriosus
747.10–747.11
Coarctation of aorta
747.20–747.22
Other anomalies of aorta
747.29
Other congenital anomalies of aorta
747.3
Congenital anomalies of pulmonary artery
747.40–747.42
Anomalies of great veins unspecified
747.49
Other anomalies of great veins
794.30–794.31
Cardiovascular, nonspecific abnormal results of function tests
794.39
Other, nonspecific abnormal results of cardiovascular function tests
Pulmonary Angiography
Medicare is establishing the following limited coverage for CPT/HCPCS code 93568:
Covered for:
415.0
Acute cor pulmonale
415.11
Iatrogenic pulmonary embolism and infarction
415.19
Other pulmonary embolism and infarction
416.0
Primary pulmonary hypertension
416.2
Chronic pulmonary embolism
416.8
Other chronic pulmonary heart diseases
424.2–424.3
Other diseases of endocardium
429.1–429.2
Ill-defined descriptions and complications of heart disease
518.81–518.82
Other diseases of lung
518.84
Acute and chronic respiratory failure
639.6
Embolism following abortion or ectopic and molar pregnancies
745.5
Ostium secundum type atrial septal defect
746.00–746.02
Anomalies of pulmonary valve
746.09
Other congenital anomalies of pulmonary valve
786.00–786.01
Dyspnea and respiratory abnormalities
786.05–786.06
Dyspnea and respiratory abnormalities
786.09
Respiratory abnormality other
V42.1
Heart replaced by transplant
V42.6
Lung replaced by transplant
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
  • Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
  • Medicare will expect that the patient’s medical record will document the patient’s clinical history and physical findings as well as relevant information regarding the course of the patient’s symptoms and findings, treatment and previous diagnostic evaluation to substantiate the medical necessity of each cardiac catheterization service billed.
  • Documentation of cardiac catheterization and angiography services must be contained in a formal report of the procedure that describes in detail each service billed.
  • Presence of a covered indication for right heart catheterization must be clearly documented in the medical record when right heart catheterization is billed.
  • Documentation must support all information submitted with the claim such as HCPCS and ICD-9-CM codes.
  • Indications for billing right or left heart catheterization at the same time of endomyocardial biopsy (CPT code 93505) must be clearly documented in the patient’s record.
  • Indications for right heart angiography when performed with right heart catheterization must be clearly documented in the patient’s record.
  • Indications for aortic root aortography when performed with cardiac heart catheterization must be clearly documented in the patient’s record.
  • The medical record must clearly demonstrate that angiography and/or intervention of extra-cardiac vessels were medically reasonable and necessary for the diagnosis and treatment of disease in accordance with accepted authoritative practice standards.

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