Left Heart Catheterization and Coronary Angiography

CPT 93454
Approach Endovascular
Add-on / Variant CPTs
  • 93458 — Left heart catheterization with coronary angiography
  • 93461 — Left heart catheterization with right heart catheterization
Preoperative Diagnosis:

[Chest pain / ACS / abnormal stress test / pre-operative cardiac evaluation / structural heart disease evaluation]

Postoperative Diagnosis:

Same

Procedure Performed:

Left heart catheterization with selective coronary angiography [and left ventriculography] [and right heart catheterization]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Cath lab nurse/tech]

Anesthesia:

Moderate sedation with local anesthesia: [X] mL 1% lidocaine at access site

Indications:

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.

Findings:

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]

Description of Procedure:

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.

Complications:

None

Specimens:

None

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

The patient was monitored post-procedure for [2–4 hours]. The access site was assessed for [hematoma / bleeding]. Creatinine was to be checked at [24 hours] given contrast administration. 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
.TODAY
Variants

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. Exceeding [4 × weight in kg] mL is associated with elevated nephropathy risk.
  • Document vascular access site assessment before discharge. Femoral access requires limb check (pulse, ABI) before discharge; radial access requires radial artery patency check (palmar arch). Document 'radial artery palpable at discharge' or 'femoral access site without hematoma, distal pulses intact.'
Billing Tips
  • Bill 93458 for left heart catheterization with coronary angiography and left ventriculography (5.46 wRVU, 0-day global). Use for diagnostic cardiac cath with left-sided evaluation only.
  • Bill 93459 when prior coronary bypass grafts are also imaged (6.19 wRVU). Bill 93460 for combined right and left heart catheterization with coronary angiography (6.92 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 sitting uses additional codes (92920-92944) billed in addition to the diagnostic catheterization.
  • 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.