This page addresses follow-up questions and additional information pertinent to our webinar
Getting Through the Op Report Without Crying: Congenital Interventional Cardiology.

** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.

Q: When may a right heart catheterization be reported separately from an endomyocardial biopsy?
A: That’s a great question, and it’s one that has generated quite a bit of discussion. The key takeaway is that the right heart catheterization is considered integral to an endomyocardial biopsy when it is performed solely to guide the biopsy or monitor right heart pressures during the procedure. In those situations, the right heart catheterization should not be reported separately.

However, there is an important exception. A complete, medically necessary right heart catheterization may be reported separately if it is performed for a distinct clinical indication unrelated to the reason for the biopsy. The documentation must clearly support that the catheterization was a separate diagnostic service and not simply part of performing the biopsy. When appropriate, modifier -59 (or XU) may also be required.

Because this has been an area of frequent audit scrutiny, it’s important to remember that medical necessity – not simply performing the catheterization – is what determines whether separate reporting is appropriate. For routine transplant surveillance, where the right heart catheterization is performed as part of the biopsy encounter, the services generally should not be reported separately.

Q: Our providers frequently perform right heart catheterizations and endomyocardial biopsies for heart transplant patients. Their documentation template states that a separate right heart catheterization is medically necessary for medication titration. Can the right heart catheterization be reported separately from the biopsy?
A: In most cases, no. A right heart catheterization performed during the same encounter as an endomyocardial biopsy is generally considered integral to the biopsy when it is performed as part of routine transplant surveillance, including monitoring hemodynamics to guide immunosuppressive medication management. Simply documenting that the catheterization is performed for “medication titration” does not, by itself, support separate reporting. To report a complete right heart catheterization in addition to the biopsy, the documentation must clearly establish that it was medically necessary for a distinct clinical indication unrelated to the transplant surveillance or biopsy. Because separate reporting is expected to be uncommon and has been the focus of payer and OIG scrutiny, providers should ensure the documentation clearly supports the independent medical necessity of the diagnostic catheterization.

Q: For Case #1 in the webinar, why wasn’t CPT code 93598 (Cardiac output measurement(s), thermodilution or other indicator dilution method during cardiac catheterization) reported when thermodilution was documented?
A: Although thermodilution was documented, CPT code 93598 is not reported solely because the technique was performed. This add-on code is specifically intended for congenital cardiac catheterization procedures and may only be reported with the primary catheterization codes identified in the CPT instructional notes. In this case, the primary procedure was reported with CPT code 93451, which is not one of the approved base codes for 93598. Because add-on codes may only be reported with their designated primary procedures, 93598 is not separately reportable, even when thermodilution cardiac output measurements are documented. When assigning add-on codes, always verify that the primary procedure is listed as an approved base code in the CPT guidelines before reporting the additional service.

Q: In case #2 of the webinar, why wasn’t a code reported for selective right and left pulmonary artery angiography? The catheter was in both branch pulmonary arteries.
A: Although the guidewires were advanced into both branch pulmonary arteries to perform angioplasty, the diagnostic angiography was performed from the main pulmonary artery before intervention. Documentation does not support selective contrast injections into the right or left pulmonary arteries. Because the diagnostic imaging was nonselective, only 93568 (nonselective pulmonary arterial angiography) is reported.

Q: In Case #3 in the webinar, why was the Glenn anastomosis stenting coded separately from the pulmonary artery stenting?
A: The right superior cavopulmonary (Glenn) anastomosis is a surgically created connection between the superior vena cava and the pulmonary artery. In this case, the chronic obstruction involved the anastomosis itself, while separate stenoses involved the proximal right lower pulmonary artery and distal right upper pulmonary artery. Because these were distinct treated vascular segments, the Glenn intervention is separately reportable from the unilateral pulmonary artery revascularization.