93461
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
7.65
Facility
$1329.02
Non-Facility
$1329.02
Documentation Required
- The patient's medical record must fully document medical necessity for the cardiac catheterization and support the diagnosis and procedures billed.
- Each claim must include ICD-10-CM diagnosis code(s) that accurately reflect the patient's condition and reason for the procedure and these codes must be linked to the CPT procedure codes on the claim.
- When a referring/ordering physician is required, the name and NPI of the referring/ordering physician must be reported on the claim; for extra-cardiac angiographic services the treating physician's name and NPI must be submitted in items 17/17a of CMS-1500 or electronic equivalent.
- For patients post-heart transplant without evidence of rejection, use primary diagnosis Z09 (follow-up after completed treatment) and secondary diagnosis Z94.1 (heart transplant status); add the underlying disorder code when coding I25.82 or I31.4.
Key Coverage Criteria
- Medicare Part B covers the professional component of cardiac catheterization and coronary angiography when performed in hospital inpatient and outpatient facility settings.
- Diagnostic cardiac catheterization performed in an office setting (where permitted) is covered under Medicare Part B for both professional and technical components.
- Global and technical component procedures are covered under Part B when performed under personal physician supervision in an IDTF, free-standing facility, physician office, or physician-directed clinic (physician present in room for entire procedure).
- Cardiac catheterization and coronary angiography are covered when the medical record documents medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests that support the procedure.
- Right heart catheterization is indicated to evaluate pulmonary hypertension.
- Right heart catheterization is indicated to evaluate valvular heart disease.
14 Active Policies
A52850 — Billing and Coding: Cardiac Catheterization and Coronary Angiography
J06
L33557 — Cardiac Catheterization and Coronary Angiography
J06
L33693 — Peripheral Venous Ultrasound
J09
L37371 — Electroretinography (ERG)
J12
A53252 — Billing and Coding: Independent Diagnostic Testing Facility (IDTF)
Related Codes
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