Left Heart Catheterization and Coronary Angiography
9345893454wRVU: 4.43 — Coronary angiography alone without left heart catheterization (alternative primary code when no LHC performed)93459wRVU: 6.19 — LHC with coronary angiography and bypass graft angiography (alternative primary code when bypass grafts are imaged)93460wRVU: 6.92 — Combined right and left heart catheterization with coronary angiography (alternative primary code)93461wRVU: 7.65 — Combined right and left heart catheterization with coronary angiography and LV-gram (alternative primary code)
[Chest pain / ACS / abnormal stress test / pre-operative cardiac evaluation / structural heart disease evaluation]
Same
Left heart catheterization with selective coronary angiography [and left ventriculography] [and right heart catheterization]
[Attending name], MD/DO
[Cath lab nurse/tech]
Moderate sedation with local anesthesia: [X] mL 1% lidocaine at access site
The patient is a [age]-year-old [male/female] presenting with [chest pain / NSTEMI / positive stress test / pre-operative evaluation for [procedure] / evaluation of structural heart disease]. Coronary angiography was indicated. The risks, benefits, and alternatives were discussed and informed consent was obtained.
LEFT MAIN: [Normal / X% stenosis]
LAD: [Normal / X% proximal stenosis / X% mid stenosis]
LCX: [Normal / X% stenosis / dominant]
RCA: [Normal / X% stenosis / dominant / total occlusion]
[Left ventriculography: EF X%, [no wall motion abnormality / anterior / inferior hypokinesis/akinesis], [no mitral regurgitation / mild MR]]
[Right heart catheterization: RA X mmHg, RV X/X mmHg, PA X/X mmHg, PCWP X mmHg, CO/CI X L/min/m²]
IMPRESSION: [Normal coronaries / Single-vessel disease (RCA 80%) / Two-vessel disease (LAD + RCA) / Three-vessel disease / Left main disease]. Recommendation: [medical management / PCI / CABG referral]
The patient was positioned supine on the catheterization table. The [right radial / right femoral / left radial] access site was prepped and draped. Local anesthesia was infiltrated. The [radial / femoral] artery was accessed with a [21-gauge / 5-Fr] micropuncture needle using modified Seldinger technique. A [5 Fr / 6 Fr] sheath was placed.
[Radial: Verapamil [2.5 mg] and nitroglycerin [200 mcg] were administered intraarterially for vasospasm prophylaxis.]
Heparin [2,500-5,000 units] was administered intravenously. Selective cannulation of the [left main / right coronary artery] was performed with [JL 4 / JR 4 / Tiger] catheter. Contrast injections were performed in multiple orthogonal views. [The right coronary artery was engaged with a [JR 4] catheter.] [Left ventriculography was performed with a [pigtail] catheter, [X] mL contrast at [X] cc/sec.]
[Right heart catheterization: A [Swan-Ganz / end-hole] catheter was advanced from the [right femoral / internal jugular] vein to the pulmonary artery. Pressures were recorded. Cardiac output was measured by [thermodilution / Fick method].]
The catheter and sheath were removed. Hemostasis was achieved with [radial band / TR Band / closure device / manual compression × 15 minutes] at the access site.
None
None
Minimal
None
The patient was monitored post-procedure for [2-4 hours]. The access site was assessed for [hematoma / bleeding]. Creatinine was to be checked at [48-72 hours] given contrast administration; CI-AKI typically peaks at 48-72 hours, not 24 hours. Findings were discussed with the patient and referring physician.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***, cardiac catheterization indicated
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Left heart cath with coronary angiography [+ LVG] [+ RHC]
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Moderate sedation + local
INDICATIONS: .PTAGE-year-old .PTSEX with ***. Cath indicated. Consent obtained.
FINDINGS:
LM: *** | LAD: *** | LCX: *** | RCA: ***
[LVG: EF ***%, WMA ***, MR ***]
[RHC: RA ***, RV ***, PA ***, PCWP ***, CO/CI ***]
IMPRESSION: ***
PROCEDURE:
Supine, cath table. *** access prepped. Local lido. *** artery accessed, Seldinger, *** Fr sheath. [Radial: verapamil/NTG.] Heparin *** units. LM cannulated *** catheter, angio *** views. RCA *** catheter. [LVG: pigtail, *** mL contrast.] [RHC: *** catheter, PA pressures, CO thermodilution.] Catheter/sheath removed. Hemostasis with ***. Access site intact.
EBL: Minimal
COMPLICATIONS: None
DISPOSITION: Monitored *** hours. Creatinine 24h. Findings discussed.
Signed: .ME, .MYDEGREE
.TODAYVariants
Percutaneous Coronary Intervention (PCI)
Following diagnostic coronary angiography demonstrating a [culprit lesion / [X]% stenosis of the LAD/RCA/LCX], PCI was performed. The [JL 4 / EBU / XB] guide catheter was placed. A [0.014-inch] coronary guidewire was advanced across the lesion. The lesion was pre-dilated with a [2.0 × 15]-mm balloon. A [3.0 × 28]-mm [drug-eluting stent (Xience / Synergy / Onyx)] was deployed at [12-14 atm]. Post-dilation with a [3.25 × 12]-mm [non-compliant] balloon was performed. Final angiography demonstrated TIMI 3 flow and <10% residual stenosis. Dual antiplatelet therapy (aspirin + P2Y12 inhibitor) was prescribed for [12 months].
Charting Tips
- Document each coronary artery and branches with percent stenosis. A catheterization report that says 'mild CAD' without quantifying each vessel is inadequate for surgical planning. Document LM, LAD (proximal/mid/distal), D1, D2, LCX, OM1, OM2, RCA (proximal/mid/distal), PDA, PL for each vessel.
- Document contrast volume administered. Contrast nephropathy risk increases with volume, particularly in patients with CKD. Document total contrast volume in the report. The Cigarroa formula (5 mL x body weight in kg / serum creatinine, capped at 300 mL) defines the safe contrast limit above which CI-AKI risk increases substantially. Document total contrast volume administered.
- Document vascular access site assessment before discharge. Femoral access requires limb check (pulse, ABI) before discharge; radial access requires post-procedure radial artery patency check (palpable radial pulse or reverse Barbeau assessment at discharge). Note: the Allen/Barbeau test is a pre-procedure patency screen; post-procedure documentation confirms patent radial artery. Document 'radial artery palpable at discharge.'
Billing Tips
- Bill 93458 for left heart catheterization with coronary angiography and left ventriculography (5.06 wRVU, 0-day global). Use for diagnostic cardiac cath with left-sided evaluation and left ventriculography.
- Bill 93459 when prior coronary bypass grafts are also imaged (5.87 wRVU). Bill 93460 for combined right and left heart catheterization with coronary angiography without LV-gram (5.84 wRVU); 93461 adds left ventriculography to 93460 (6.40 wRVU).
- 0-day global period: sheath removal, access site management, and same-day post-procedure monitoring are bundled. Percutaneous coronary intervention (PCI) at the same session is separately billable (92920-92944), but requires modifier -59 to unbundle the diagnostic catheterization from the PCI. Per CMS/NCCI, the diagnostic study is generally not separately billable when PCI was planned in advance; it is billable when the angiography result was the deciding factor for proceeding to PCI.
- The -26 modifier (professional component) applies when a cardiologist provides interpretation but does not own the equipment, which is common in hospital-based labs. Confirm with your billing team whether to bill globally or with -26.
- Radial artery access for cardiac catheterization does not change the procedure code. Document access site (radial vs. femoral), sheath size, and closure technique for procedural completeness.
General coding reference. Verify with your institution’s billing department before submitting claims.