Coding Guidelines for Swan-Ganz Catheterization

Swan-Ganz Catheterization procedure commonly includes insertion of a flexible, balloon-tipped catheter into the pulmonary artery for bedside diagnosis or hemodynamic monitoring of the critically ill patient. This procedure includes cannulation of a central vein, such as the subclavian or internal jugular vein, through which a flow-directed catheter is advanced into the right atrium (RA), right ventricle (RV), and pulmonary artery (PA). The catheter may be “wedged” briefly into a small pulmonary artery branch for estimation of the left atrial filling pressure. Direct pressure measurements are obtained in each chamber, the pulmonary artery and wedge, and recorded. 
In addition, other hemodynamic parameters such as the cardiac output, systemic vascular resistance (SVR), mixed venous oxygen saturation, and intrapulmonary shunt fraction may be measured or calculated and are included in the procedure. Swan-Ganz catheterization includes the insertion of a central venous line when performed via the same introducer or catheter. Repeat measurements and calculations may be performed by hospital personnel and/or are included in E&M medical decision making, and are not separately reimbursable to physicians or non-physician providers.

Indications for Swan-Ganz Catheterization

Swan-Ganz catheterization may be indicated in the following situations:

1. Acute myocardial infarction with hemodynamic instability or septal rupture;

2. Severe hypotension of unknown etiology, especially if the response to initial therapy is inadequate (e.g., volume loading);

3. Selected cases of septic shock;

4. Adult respiratory distress syndrome, to confirm the diagnosis of non-cardiogenic pulmonary edema (normal “wedge” pressure) and to aid in subsequent fluid and ventilator management;

5. Suspected cases of cardiac tamponade, to confirm the diagnosis, monitor hemodynamics during pericardiocentesis, and follow response to therapy;

6. Suspected papillary muscle rupture;

7. Congestive heart failure responding poorly to diuretics, especially when intravascular volume status is uncertain;

8. Intraoperative monitoring of patients undergoing open heart surgery, abdominal aortic aneurysm repair, or non-cardiac surgery in high-risk patients with known severe cardiac conditions;

9. Drug overdose, especially when the risk of acute lung damage is high (e.g., heroin, aspirin);

10. Exacerbations of chronic obstructive lung disease requiring intubation; when it is anticipated that hemodynamic monitoring may detect occult or superimposed causes of respiratory failure not suspected clinically (e.g., left ventricular dysfunction);

11. End-stage liver failure with deteriorating renal function;

12. Suspected cases of pulmonary hypertension.

In general, Swan-Ganz catheterization is indicated when measurement of right atrial/ventricular, pulmonary artery, and pulmonary artery wedge pressures will significantly alter patient management.

Limitations for Swan-Ganz Catheterization

This procedure is usually performed at the bedside in the critical care unit or emergency department, or in the operating room.

There is no additional reimbursement for a Swan-Ganz performed in conjunction with electrophysiologic tests or intervention, HIS bundle studies, pacing studies, temporary pacemaker insertion, interventional cardiac procedures or angioplasty, and endomyocardial biopsy catheterization done for reasons other than hemodynamic evaluation of active cardiac pathophysiology.

Swan-Ganz catheterization with hemodynamic measurements done at the same time as these other procedures will still have to be medically necessary based upon the underlying cardiovascular pathophysiology. Swan-Ganz catheterization for the purpose of routine monitoring of hemodynamic status during an electrophysiologic or other interventional cardiac procedure or angioplasty is included in that procedure and is not separately reimbursable.

There is no additional reimbursement to leave a catheter in place for monitoring at the conclusion of Swan-Ganz catheterization, or for its subsequent removal. Subsequent hemodynamic measurements (including the inflation of the catheter tip balloon) and blood sampling are not reimbursable under Part B as these functions may be performed by technicians and nurses in a hospital setting and do not require the skill of a physician. Repositioning of an existing catheter is not separately reimbursable and is included in an evaluation and management code.

Swan-Ganz catheterization is not indicated for:
1. Atherosclerotic heart disease without heart failure; or
2. Angioplasty, electrophysiologic or other interventional procedures.

See also ‘Complete Coding Guidelines for LHC, RHC and Coronary Angiography procedures‘