Are you ready for ICD-10? Part II – Cardiology Documentation


Cardiac Catheterization ICD-10 CodingIn an earlier post on ICD-10 readiness, I discussed the move to ICD-10 and why it will be a better system once we get used to it. As I mentioned in that post, there are certain requirements for documentation during cardiology procedures in order for the appropriate codes to be applied, and as a result, the appropriate reimbursement to occur.

Here are some guidelines and recommendations for documentation that should occur in the cardiac catheterization lab. These guidelines include the necessary information required. This post includes the required documentation for cardiac catheterization and PCI, as well as some of the new ICD-10 PC codes.


Required Documentation:

  1. Document if left heart only, right heart only or both right and left heart viewed under fluoroscopy.
  2. Angiography: Document the number of sites within the coronary tree.
    1. Example: Angiography was performed on _____ (#) sites. (LM, RCA, LCA, Circ = 4 sites)
  3. Document angiography of bypass grafts, whether single or multiple.
    1. Example: Angiography was performed on single/multiple bypass grafts.
    2. Example: Angiography was performed on right/left internal mammary artery graft.
    3. Example: Angiography was performed on other bypass graft.
  4. Document if left ventriculogram was performed:
    1. Example: Left ventriculogram was/was not
  5. Document type of contrast utilized.
    1. Example: High/low/Other osmolar contrast was used for angiography.
  6. PTCA: Document the number of sites dilated.
    1. Example: Dilatation was performed on ____ (#) sites.  (Proximal LAD and mid LAD, or Mid LAD and proximal RCA = 2 sites).
  7. Stent: Document stent with placement site, and indicate DES or BMS was deployed.
    1. Example: Dilatation was performed on one site with insertion of DES stent, and dilatation was performed on one site with insertion of a BMS. (PTCA of Proximal LAD with DES and proximal RCA with BMS.)
  8. Peripheral angiography during cardiac cath procedure: indicate body part.
    1. Example: Renal angiography or femoral angiography for closure placement: either left, right or bilateral renal arteries, or right/left/bilateral lower extremities.
  9. Continuous monitoring of patient: Indicate what is being monitored:
    1. Example: Continuous cardiac monitoring performed to include electrical activity, output, rate, rhythm, sound, total activity throughout the procedure.  (Most cardiac cath cases will respond “total activity”.)
  10. Individual pressure sampling: Indicate right, left or bilateral heart samples.
    1. Example: Pressure measurements were obtained in the right/left/bilateral.
    2. Example: Cardiac output measured by Fick/Thermodilution.
  11. Extracorporeal assistance (Balloon pump, Impellar device, etc).
    1. An intra-aortic balloon pump/impellar device was inserted and maintained throughout the procedure.


Possible Codes:

Heart Cath:

B2151ZZ:          Left Heart Cath with Ventriculography: (Using low osmolar contrast such as Hexabrix or Visipaque)

B2161ZZ:          Right and Left Heart Cath with Ventriculography (Low osmolar contrast)

B214ZZZ:         Right Heart Cath Only (no contrast)

B2111ZZ:          Arteriography: Multiple Coronary Arteries (Low osmolar contrast)

B2121ZZ:          Arteriography: Single Coronary Artery Bypass Graft (Low osmolar contrast)

B2131ZZ:          Arteriography: Multiple Coronary Artery Bypass Grafts (Low osmolar contrast)

Non-coronary Arteriography:

B2171ZZ:          Arteriography:  Left Internal Mammary Artery (Low osmolar contrast)

B2181ZZ:          Arteriography:  Right Internal Mammary Artery (Low osmolar contrast)

B3101ZZ:          Arteriography:  Thoracic Aorta (Low osmolar contrast)

B4161ZZ:          Arteriography:  Right Renal Artery (Low osmolar contrast)

B4171ZZ:          Arteriography:  Left Renal Artery (Low osmolar contrast)

B4181ZZ:          Arteriography: Bilateral Renal Artery (Low osmolar contrast)


4A023N6:         Measurement, Pressure and Sampling Right Heart

4A023N7:         Measurement, Pressure and Sampling Left Heart

4A023N8:         Measurement, Pressure and Sampling Bilateral Left and Right Heart

410239Z:          Measurement, Pressure and Sampling Cardiac Output

4103XB1:          Monitoring Peripheral Arterial Pressure Externally

4A03XR1:         Monitoring peripheral arterial saturation Externally

4A0345C:         Monitoring coronary arterial flow

Balloon Pump:

5A02210:          Continuous use of intra-aortic balloon pump

5A02110:          Intermittent use of intra-aortic balloon pump

I hope this helps you as you make your way through ICD-10 coding.

Stay up-to-date on the latest medical imaging issues by subscribing to the Medical Imaging Talk Blog today.

Leave a Reply