Caution ahead: Coding of right heart caths (RHC) with a biopsy

May 2, 2018 / By Rebecca Caux-Harry

At AAPC’s annual Healthcon conference in Orlando, Florida, Dr. David Zielske (also known as Dr. Z) had a session on Interventional Radiology, Cardiology and Vascular Surgery coding. As you can imagine, his session was completely full and I was fortunate to be one of the attendees. Aside from the session offering great information, presented by someone who knows both the clinical and coding sides, Dr. Z is considered the go-to expert for all things coding in this realm. And this realm continues to expand.

One point of discussion caught my attention: Coding of right heart caths (RHC) with a biopsy. The codes at issue are: 93505 Endomyocardial biopsy and 93451 Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed.

A right heart cath is bundled with endomyocardial biopsy because the biopsy is performed via RHC. However, a modifier can bypass the edit when appropriate. But, when is it appropriate to bypass this edit? The biopsy can be done for several reasons, but the most common reason is to evaluate a heart transplant patient and possible or ongoing rejection. A RHC is a diagnostic procedure usually performed to evaluate valvular, congestive, or congenital heart disease, cor pulmonale, pulmonary hypertension, intracardiac shunts, endocarditis and myocarditis, cardiogenic shock, MI, and yep, you guessed it, transplanted heart or valve. It’s this last indication that trips up most of us. 

Direction provided via the December 2017 CPT Assistant stated, “it is not appropriate to code 93451….if the catheterization is performed solely to obtain the biopsy.  Right heart catheterization may only be reported, if it is performed for a separate clinical indication and not merely as a means for obtaining the endomyocardial biopsy.” That seems pretty clear, yet I’ve never seen a report describe the procedure as placing the catheter and obtaining the biopsy.  Every report, and I mean EVERY, details the diagnostic portions of the right heart catheterization, obtaining measurements, cardiac output, etc. In fact, Tufts University fought back against the OIG and the 2009-2010 Medicare Compliance Review , stating that “both a RHC and a heart biopsy are critical to monitoring post heart transplant patients to identify, as early as possible, any indication of life-threatening tissue rejection.” Because of the date of this review, you can see this isn’t a new issue. These are very sick patients, on some very strong anti-rejection medications, therefore ongoing monitoring and follow-up is medically necessary.

So, is the diagnostic right heart cath performed during the same setting as an endomyocardial biopsy on a heart transplant patient ever appropriately reported separately?  According to Dr. Z, only in the circumstance of a different indication from that of the biopsy. And by different, I don’t think he means Z94.1 heart transplant status, and T86.21 heart transplant rejection. While the provider might be treating the patient for transplant rejection, the biopsy, according to the OIG, is the only service that should be reported. 

This has been a gray area of coding for as long as I can remember, and the OIG has had these procedures on their worklist multiple times. CMS has agreed with OIG findings that most of the RHCs coded with a biopsy are coded in error. So, be very careful when submitting claims for this service to validate both procedure codes are appropriate to report and that each service was performed for a different indication. Happy coding!

Rebecca Caux-Harry, CPC, is the CodeRyte product specialist for cardiology with 3M Health Information Systems.

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