General Surgery Coding Alert

Understand CVA edits.

Your surgeon might perform Swan-Ganz catheter (SWC) procedures for many clinical reasons. That means you need to focus on details in the op report to make sure you get the procedure coding right.

We’re here to help with four simple steps that you can take to break down the report and get the coding right.

Step 1: Understand SWG Descriptor and Function

The SGC is a long, thin tube with an inflatable balloon tip on the end that helps the catheter move smoothly through the blood vessels and heart. Providers will place an introducer sheath into a major vein such as the internal jugular, subclavian, femoral, which lets the catheter enter the body more easily. At that point, blood flow directs the SGC through the veins, into the right side of the heart, and then into the pulmonary arteries (PAs) that carry blood to the lungs.

The SGC has many ports, each with a specific function:

• Putting fluid or medication into the heart.
• Checking blood pressure in various locations.
• Inflating a tiny balloon that helps with SGC placement in the PA.
• Taking a blood sample from the PA.

Providers typically place an SGC in patients with certain types of severe cardiac conditions or whose cardiac function might be compromised prior to or during surgery.

Terminology: You might see the Swan-Ganz catheter referred to as a pulmonary artery catheter (PAC) or as a balloon flotation flow-directed catheter.

Step 2: Distinguish Similar Procedures

Providers use SGC as a diagnostic tool to monitor heart and lung function, evaluate hemodynamics, and determine the effectiveness of medications. They use the SGC to measure important indicators of cardiovascular function including central venous pressure (CVP), right atrial pressure, PA pressure, cardiac output (amount of blood ejected by the heart per minute), and venous oxyhemoglobin saturation (SvO2).

CPT^®: Report 93503 (Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes) “for placement of a flow directed catheter (e.g., Swan-Ganz) performed for hemodynamic monitoring purposes not in conjunction with other catheterization services,” per the CPT^® guidelines. Do not report 93503 in conjunction with other diagnostic cardiac catheterization codes.

Don’t miss: Because providers use an SGC in a right heart catheterization (RHC) procedure, you might be confused about whether a procedure is an RHC or really an SGC insertion for hemodynamic monitoring.

Tip: A good way for you to distinguish the procedures is that when an SGC is inserted, hemodynamics are taken, and at the end of the procedure, the provider leaves the catheter in instead of removing it.

“Although the hemodynamic measurements taken are the same whether [the procedure is] an SGC or a right heart catheterization, an SGC is usually done at the bedside; hemodynamic measurements are taken, and the catheter is sutured in place,” says Robin Peterson, CPC, CPMA, manager of professional coding and compliance services, Pinnacle Enterprise Risk Consulting Services, LLC in Centennial, Colorado. “A right heart catheterization is typically performed in the cardiac catheterization lab; hemodynamic measurements are taken, and the catheter is removed from the body.”

Step 3: Handle Multiple Catheters With Care

If your provider uses multiple catheters in the procedure, you must see which you can separately report. Documentation of other lines placed in addition to the SGC doesn’t automatically mean you can report each line separately.

Key: “One detail you must confirm to get the coding right is the number of access sites,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, product manager, MRO, in Philadelphia.

For example, central venous catheter placement (CVC) is included in the SGC fee. So if your provider places an SGC and threads it through a CVC line, the central line (36555 or 36556, Insertion of non-tunneled centrally inserted central venous catheter …) is considered part of the SGC when your surgeon places it through the same access site.

If you have clear documentation supporting the separate sites, append modifier 59 (Distinct procedural service) or XS (Separate structure …) to the central line code to override the National Correct Coding Initiative (NCCI) edit pair.

Sometimes, your provider also places an arterial line in addition to the SGC. If they document the two or all three lines, you can report both the arterial line (36620, Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous) and the SGC (93503) on your claim.

Step 4: Clarify Medical Necessity for SGC

When it comes to ICD-10-CM codes, review the patient’s chart and medical history for potential diagnoses that would support medical necessity. Providers often use SGC for circumstances including:

• For certain patients with acute respiratory distress syndrome (ARDS), myocardial infarction, or severe chronic heart failure (such as I21.-, Acute myocardial infarction);
• To diagnose right ventricular failure (such as I50.-, Heart failure); or
• To distinguish between pre- and post-capillary pulmonary hypertension (such as I27.20, Pulmonary hypertension, unspecified).

Notice: If your surgeon is involved in trauma treatment using SGC, you should note that critical care services are separately reportable.