Identify Echocardiogram and Heart Catheterization Codes for an ED Encounter
Question: I have an encounter note with a 78-year-old patient who presented to the emergency department (ED) with shortness of breath, fatigue, and a rapid heartbeat. The pulmonologist ordered an echocardiogram and a right heart catheterization. Testing showed elevated pulmonary artery pressure. After reviewing the results, performing a physical examination, and examining the patient’s history, the pulmonologist diagnosed the patient with primary pulmonary hypertension and prescribed them vasodilators. How do I report the pulmonologist’s work? Ohio Subscriber Answer: You’ll assign two CPT® codes to report the pulmonologist’s work. Use 93306 (Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography) to report the echocardiogram. You’ll then assign 93451 (Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed) for the right heart catheterization. While the pulmonologist performed these procedures during the ED visit, you’ll also need to report a diagnosis code to show the medical necessity for the procedures. The provider diagnosed the patient with primary pulmonary hypertension, which means you’ll use I27.0 (Primary pulmonary hypertension) as the diagnosis code for the procedures. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
