116 Form

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Medical Policy Cardiac Catheterization and Coronary Angiography Table of Contents • Policy: Commercial • Description • Information Pertaining to All Policies
• Authorization Information • Policy History • Endnotes • Coding Information • References

Policy Number: 116 BCBSA Reference Number: N/A Related Policies
Percutaneous Coronary Intervention, #117 Policy1 Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

The guidelines in this policy outline the indications for coverage of each procedure.

1. Right Heart Catheterization
2. Left Heart Catheterization
3. Left Heart Catheterization by Transseptal Puncture
4. Cardiac Angiography
5. Pulmonary Angiography
6. Intra-Coronary Ultrasound and Doppler Functional Flow Reserve Studies
7. Physiologic Exercise Study with Hemodynamic Measurement

8. Angioplasty/Stent Placement/Atherectomy

   Right Heart Catheterization
   Right heart catheterization is MEDICALLY NECESSARY to evaluate:

9. Valvular heart disease.
10. Congestive heart failure.
11. Congenital heart disease.
12. Cor pulmonale.
13. Pulmonary hypertension.
14. Intracardiac shunts (including septal rupture) and extracardiac vascular shunts.
15. Suspected cardiomyopathy or myocarditis.
16. Endocarditis anticipated to require valvular surgical repair.
17. Suspected rejection of a transplanted heart.

18. Suspected pericardial tamponade or constriction.

    Right heart catheterization is NOT MEDICALLY NECESSARY for:

19. Atherosclerotic heart disease without heart failure; or

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2. Coronary angioplasty, electrophysiologic studies or other interventional procedures.

   Left Heart Catheterization
   Left heart catheterization is considered MEDICALLY NECESSARY for the diagnosis of, or treatment planning for:

3. myocardial abnormalities or dysfunction (including ischemic disease, myocarditis, cardiomyopathy)
4. valvular dysfunction
5. intracardiac shunts
6. congenital heart abnormalities
7. cardiac trauma

8. pericardial tamponade.

   Left Heart Catheterization by Transseptal Puncture The transseptal catheterization may be considered MEDICALLY NECESSARY in those cases in which:

9. access to the left ventricle is required for hemodynamic measurements or angiography, when retrograde arterial access is not feasible or appropriate
10. access to the left atrium and pulmonary veins is necessary for hemodynamic measurements and angiography

11. access to the left atrium and ventricle is necessary for the performance of diagnostic and therapeutic electrophysiological procedures.

    Cardiac Angiography
    Angiograms of the individual cardiac chambers (atria and ventricles) are considered MEDICALLY NECESSARY for the assessment of:

12. mitral or tricuspid valve function
13. ventricular function or morphology (including tumors and clots)
14. suspected ventricular aneurysms
15. intracardiac shunts
16. congenital heart disease

17. cardiac trauma.

    Coronary and bypass angiography are considered MEDICALLY NECESSARY for the diagnosis of, or treatment planning for:

18. anginal syndromes
19. atypical chest pain syndrome suggesting ischemia
20. congenital heart disease
21. following cardiac arrest suspected to be due to ischemia or infarction
22. myocardial infarction
23. known atherosclerotic or other coronary disease
24. suspected graft or stent/PTCA closure
25. Prinzmetal’s angina
26. coronary shunts and fistulae
27. cardiac trauma
28. non-coronary cardiac surgical procedures (e.g., aortic or mitral valve surgery when not requiring left heart catheterization).

29. non-cardiac surgical procedures (arterial or aortic surgery, or surgery with large fluid shifts) in high- risk patients with evidence of ischemic heart disease.

    Pulmonary Angiography
    Pulmonary angiography is MEDICALLY NECESSARY for:

30. suspected pulmonary emboli
31. pulmonary hypertension
32. pulmonary A-V malformations or shunts
33. pulmonary artery stenosis
34. congenital heart disease affecting the pulmonary vasculature including pulmonary venous return.

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Intracoronary Ultrasound and Doppler Functional Flow Reserve Studies
Intracoronary ultrasound may be considered MEDICALLY NECESSARY to assess the extent of coronary stenosis if equivocal on angiography, or to assess the patency and integrity of a coronary artery post- intervention.

Physiologic Exercise Study with Hemodynamic Measurement The performance of physiologic exercise to assess hemodynamic effects is MEDICALLY NECESSARY when performed as a diagnostic test to evaluate cardiac abnormalities such as valve dysfunction, ventricular dysfunction or shunt ratios.

All such interventions must include pre-, intra- and post-exercise measurement of ventricular function (e.g., ejection fraction or wall motion) or hemodynamics.

Angioplasty/Stent Placement/Atherectomy
The interventional procedures: percutaneous transluminal angioplasty, coronary stent placement and atherectomy are described in a separate policy (#117) Percutaneous Coronary Intervention.

Extra-Cardiac Angiography performed with Cardiac Catheterization Extra-cardiac angiography (e.g., injection of the abdominal aorta, carotid, ileofemoral or renal arteries) is sometimes performed during the same session with cardiac catheterization.

These procedures are considered MEDICALLY NECESSARY for the following conditions:

1. a transient ischemic attack
2. hypertensive heart and kidney disease
3. atherosclerosis
4. aneurysm
5. embolism and thrombosis

6. artery dissection.

   Prior Authorization Information
   Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
   Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

   Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required.

   CPT Codes / HCPCS Codes / ICD Codes
   Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

   Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

   The following codes are included below for informational purposes only; this is not an all-inclusive list. The above medical necessity criteria MUST be met for the following CPT codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

   CPT Codes

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CPT codes:

Code Description 93451 Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed 93453 Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed 93456 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization 93457 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 93460 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 intraprocedural injection(s) for left ventriculography, when performed 93461 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 intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography

Link to A52850 Billing and Coding: Cardiac Catheterization and Coronary Angiography covered ICD diagnosis codes

The above medical necessity criteria MUST be met for the following CPT codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

CPT Codes CPT codes:

Code Description 93452 Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed 93453 Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed 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 93459 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, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography 93460 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 intraprocedural injection(s) for left ventriculography, when performed 93461 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 intraprocedural

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injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography

Link to A52850 Billing and Coding: Cardiac Catheterization and Coronary Angiography covered ICD diagnosis codes

In addition to the covered diagnosis codes in Billing and Coding Article A52850, the following ICD diagnosis code is considered medically necessary for commercial products when submitted with the CPT/HCPCS codes above if medical necessity criteria are met:

ICD-10 Diagnosis Codes ICD-10-CM diagnosis codes: Code Description I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site

The above medical necessity criteria MUST be met for the following CPT codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

CPT Codes CPT codes:

Code Description 93454 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; 93455 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 93456 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization 93457 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

Link to A52850 Billing and Coding: Cardiac Catheterization and Coronary Angiography covered ICD diagnosis codes

The above medical necessity criteria MUST be met for the following CPT codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

CPT Codes CPT codes:

Code Description 93593 Right heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone; normal native connections 93594 Right heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone; abnormal native connections

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93595 Left heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone, normal or abnormal native connections 93596 Right and left heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone(s); normal native connections 93597 Right and left heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone(s); abnormal native connections 93598 Cardiac output measurement(s), thermodilution or other indicator dilution method, performed during cardiac catheterization for the evaluation of congenital heart defects (List separately in addition to code for primary procedure)

Link to A52850 Billing and Coding: Cardiac Catheterization and Coronary Angiography covered ICD diagnosis codes

The above medical necessity criteria MUST be met for the following CPT code to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

CPT Codes CPT codes:

Code Description 93505 Endomyocardial biopsy

Link to A52850 Billing and Coding: Cardiac Catheterization and Coronary Angiography covered ICD diagnosis codes

In addition to the covered diagnosis codes in Billing and Coding Article A52850, the following ICD diagnosis code is considered medically necessary for commercial products when submitted with the CPT/HCPCS codes above if medical necessity criteria are met:

ICD-10 Diagnosis Codes ICD-10-CM diagnosis codes: Code Description I40.9 Acute myocarditis, unspecified

Extra-Cardiac Angiography Performed During the Same Encounter as Cardiac Catheterization

Note: In addition to the covered diagnosis codes in Billing and Coding Article A52850, any procedure code from column 1 must be accompanied by any procedure code from column 2 and any procedure code from column 3 to be considered medically necessary.

Link to A52850 Billing and Coding: Cardiac Catheterization and Coronary Angiography covered ICD diagnosis codes

Column 1 CPT/HCPCS code Column 2 CPT/HCPCS code Column 3 CPT/HCPCS code 75625 36140 93451 75630 36200 93453 75705 36215 93456 75710 36216 93457 75716 36217 93460

36218 93461

93452

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93458 93459 93454 93455 93593 93594 93595 93596 93597 93598 Description Cardiac catheterization is the introduction and positioning of a catheter in the heart to assess cardiac function and structure, for diagnosis, treatment planning or to assess therapy. This assessment may include the measurement of intracardiac and intra- vascular pressures, obtaining blood samples for blood gas or other constituent analysis, determination of cardiac output, injection of contrast for angiography, and performing endomyocardial biopsy. The conduct and evaluation of these procedures are then documented and interpreted by the physician, in a report.

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 diagnostic procedures including coronary and bypass angiography, angiography of the cardiac chambers, aortic and pulmonary angiography, endomyocardial biopsy, and extra-cardiac angiography.

The guidelines in this policy outline the indications for coverage of each procedure:
• Right Heart Catheterization Indications • Left Heart Catheterization Indications and Limitations • Left Heart Catheterization by Transseptal Puncture • Cardiac Angiography Indications and Limitations • Pulmonary Angiography Indications • Intra-Coronary Ultrasound and Doppler Functional Flow Reserve Studies • Pharmacologic Agent Administration with Hemodynamic Assessment • Physiologic Exercise Study with Hemodynamic Measurement • Angioplasty/Stent Placement/Atherectomy Indications and Limitations.

Right Heart Catheterization This is the introduction of a catheter(s) into the right atrium, right ventricle and pulmonary artery. It generally includes hemodynamic measurements, and cardiac output determination, and may also include, when medically indicated, shunt determinations, and/or blood sampling, and/or hydrogen arrival time 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. Right heart catheterization is a formal diagnostic procedure (with report) performed in a catheterization or other procedure suite, as compared to Swan-Ganz catheterization which is generally performed for ongoing monitoring of the patient (after the initial diagnostic results are recorded), performed at the bedside, or in an operating room, emergency department or other intensive/critical care unit. The results of the Swan- Ganz catheterization may be recorded in the progress notes rather than by a formal report.

Right heart catheterization, performed along with left heart catheterization, coronary angiography, or both, is seldom medically reasonable and necessary unless one disease process appears to affect both sides of the heart, or a different disease process appears to affect each side of the heart. Left Heart Catheterization This is the introduction of a catheter(s) into the left ventricle (LV). The catheter may be inserted retrograde from the brachial, axillary or femoral artery; by cutdown or percutaneously; or transseptally via a patent foramen ovale or by septal puncture; or transapically. The catheterization also includes

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catheterization of the left atrium and aorta when performed with the LV catheterization. It includes all hemodynamic measurements (with and without maneuvers and/or infusions or medication), blood sampling and shunt determinations as part of the procedure. Placement of multiple catheters and their repositioning or replacement is included in this procedure.

Left Heart Catheterization by Transseptal A catheter with an enclosed transseptal puncture needle is positioned into the right atrium, and under fluoroscopic and/or ultrasonic guidance is advanced, puncturing an intact intra-atrial septum thereby entering the left atrium. The needle is then removed, leaving the catheter through which a guide wire may be advanced to facilitate placement of appropriate catheters into the left atrium and left ventricle. This procedure should not be billed if the catheter is advanced into the left atrium through a patent foramen ovale or atrial septal defect.

Coronary angiography
Coronary angiography is a single procedure which includes arteriograms of all coronary arteries and their branches, regardless of the number of vessels selectively catheterized or visualized, with and without the administration of diagnostic or therapeutic vasoactive medications.

Policy History Date Action 8/2025 Intracoronary ultrasound section clarified to remove this statement: intravascular doppler velocity and/or pressure derived coronary flow reserve measurement may be medically necessary to assess the degree of stenosis within a vessel. This medically necessary statement is addressed in MP 117 Percutaneous Coronary Intervention. Codes 93571-

93572. 11/2024 Updated link to A52850. 10/2024 New medical policy describing medically necessary and not medically necessary indications. Effective 10/1/2024. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References
93573. American College of Cardiology/American Heart Association Task Force. Guidelines for coronary angiography. J Am Coll Cardiol. 1987;10:935-950.
93574. American College of Cardiology Position Statement on Right Heart Catheterization. Adopted by the American College of Cardiology Executive Committee on March 9, 1985; re-approved in 1990.
93575. American College of Cardiology/American Heart Association Ad Hoc Task Force on Cardiac Catheterization. ACC/AHA guidelines for cardiac catheterization and cardiac catheterization laboratories. J Am Coll Cardiol. 1991;18(5):1149-1182.
93576. American College of Cardiology/American Heart Association Task Force. Guidelines for the evaluation and management of heart failure. J Am Coll Cardiol. 1995;26:1376-1398.
93577. Braunwald E. Heart Disease: A Textbook of Cardiovascular Medicine. Sixth Edition. St. Louis, MO: WB Saunders Co; February 2001.
93578. HealthGate Data Corporation. Swan-Ganz Catheterization. May 1998.
93579. Other carrier’s local medical review policy (legacy Empire Medicare Services Part B and Administer Federal Part B).
93580. Practice Guidelines for Pulmonary Artery Catheterization: A report by the American Society of Anesthesiologists Task Force on pulmonary artery catheterization. Anesthesiology. 1993;78:380-394.

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Endnotes

1 Local Coverage Determination (LCD) Cardiac Catheterization and Coronary Angiography L33557 Billing and Coding: Cardiac Catheterization and Coronary Angiography A52850 Last revision date: 10/1/2019