Normal native connections exist when the pathway of blood flow follows the expected course through the right and left heart chambers and great vessels (ie, superior vena cava [SVC]/inferior vena cava [IVC] to right atrium, then right ventricle, then pulmonary arteries for the right heart; left atrium to left ventricle, then aorta for the left heart). Examples of congenital heart defects with normal connections would include acyanotic defects such as isolated atrial septal defect, ventricular septal defect, or patent ductus arteriosus. Services including right heart catheterization for congenital cardiac anomalies with normal connections are reported with 93593, 93596.
When contrast injection(s) is performed in conjunction with cardiac catheterization for congenital heart defects, see injection procedure codes 93563, 93564, 93565, 93566, 93567, 93568, 93569, 93573, 93574, 93575, 93584, 93585, 93586, 93587, 93588, or use appropriate codes from the Radiology section and the Vascular Injection Procedures subsection in the Surgery/Cardiovascular System section. For venography of the IVC, report 75825. For venography of the SVC, report 75827. Venography of an anomalous or persistent SVC (93584), the azygous/hemiazygous venous system (93585), the coronary sinus (93586), or venovenous collaterals (93587, 93588) requires catheter placement(s) distinct from that required for congenital right and left heart catheterization. Therefore, 93584, 93585, 93586, 93587, 93588 include catheter placement in addition to venography. Codes 93563, 93564, 93565, 93566, 93567, 93568, 93569, 93573, 93574, 93575, 93584, 93585, 93586, 93587, 93588 include imaging supervision, interpretation, and report.
Injection procedures 93563, 93564, 93565, 93566, 93567, 93568, 93569, 93573, 93574, 93575, 93584, 93585, 93586, 93587, 93588 represent separate, identifiable services and may be reported in conjunction with one another, when appropriate. For angiography of other noncoronary and nonpulmonary arteries and veins, performed as a distinct service, use appropriate codes from the Radiology section and the Vascular Injection Procedures subsection in the Surgery/Cardiovascular System section.
Venography: Catheter placement in a normal SVC and a normal IVC is considered as part of a standard congenital cardiac catheterization. When venography of the normal IVC is performed, report 75825. When venography of the normal SVC is performed, report 75827. For coding purposes, the term “anomalous/persistent left or right SVC” refers to a second SVC on the opposite side of the chest from the first SVC. For example, in a typical cardiac anatomy, the SVC is on the right side and a persistent left SVC would be on the left side. In situs inversus, the SVC would typically be located on the left side of the chest and a persistent right SVC would be on the right side. In heterotaxy, bilateral SVCs are common. In these scenarios, venography of the first SVC would be reported with 75827, and catheter placement and venography of the persistent/anomalous SVC would be reported with 93584.
Selective catheter placement in anomalous congenital venous structures is not included in a standard congenital cardiac catheterization. Therefore, add-on codes 93584, 93585, 93586, 93587, 93588 include selective catheter placement in the specific venous structure(s) being imaged as well as venography and radiologic supervision, interpretation, and report.
93584 Venography for congenital heart defect(s), including catheter placement, and radiological supervision and interpretation; anomalous or persistent superior vena cava when it exists as a second contralateral superior vena cava, with native drainage to heart (List separately in addition to code for primary procedure)
(Use 93584 in conjunction with 93593, 93594, 93596, 93597)
(Report 93584 once per session)
93585 azygos/hemiazygos venous system (List separately in addition to code for primary procedure)
(Use 93585 in conjunction with 93593, 93594, 93596, 93597)
(Report 93585 once per session)
93586 coronary sinus (List separately in addition to code for primary procedure)
(Use 93586 in conjunction with 93593, 93594, 93596, 93597)
(Report 93586 once per session)
93587 venovenous collaterals originating at or above the heart (eg, from innominate vein) (List separately in addition to code for primary procedure)
(Use 93587 in conjunction with 93593, 93594, 93596, 93597)
(Report 93587 once per session)
93588 venovenous collaterals originating below the heart (eg, from the inferior vena cava) (List separately in addition to code for primary procedure)
(Use 93588 in conjunction with 93593, 93594, 93596, 93597)
(Report 93588 once per session)
Certain congenital cardiac abnormalities can negatively affect the performance of both diagnostic and interventional cardiac procedures. When abnormalities such as heterotaxy syndrome, complex single ventricle physiology, and others are present, venography can help identify and assess these abnormalities and aid the clinician in performing the definitive cardiac catheterization procedure. New codes 93584-93588 describe add-on venography services that are performed during cardiac catheterization for congenital heart defects (93593-93597). These procedures involve different and more complex work to navigate abnormal structures than venography that is performed on normal cardiac anatomy, thereby differentiating them from existing codes 75825, Venography, caval, inferior, with serialography, radiological supervision and interpretation, and 75827, Venography, caval, superior, with serialography, radiological supervision and interpretation.
Note that radiological supervision and interpretation are included in the work of the new codes; therefore, it would not be appropriate to report these services separately. In addition, the new add-on codes specify which vessel or venous system is treated and are reported once per session. Table 1 clarifies the intended use of these add-on codes based on the treated vessel or venous system.
New Codes for Venography (Vessel or Venous System)
93584 Superior vena cava
93585 Azygos/hemiazygos venous system
93586 Coronary sinus
93587 Venovenous collaterals originating at or above the heart (eg, from the innominate vein)
93588 Venovenous collaterals originating below the heart (eg, from the inferior vena cava)
The following clinical examples and procedural descriptions reflect typical clinical scenarios for which these new codes would be appropriately reported.
Clinical Example (93584)
A 5-month-old female with hypoplastic left heart syndrome, whose status is post-Norwood operation, is identified with an anomalous superior vena cava (SVC) during a diagnostic right and left cardiac catheterization in preparation for next-stage cavopulmonary anastomosis, has venography to aid surgical planning. [Note: This is an add-on code. Only consider the additional work related to achieving catheter placement and performance of anomalous superior vena cava venography.]
Description of Procedure (93584)
Insert an end-hole guide catheter through a venous sheath and, with guidewire assistance, into an SVC. Perform venography with contrast injection. If present, a second SVC that requires incorporation into a surgical cavopulmonary anastomosis is entered. (Catheter placement is reported separately with the diagnostic cardiac catheterization codes for congenital heart disease.) Repeat venography with contrast injection to delineate the vessel course.
Clinical Example (93585)
A 2-month-old male with heterotaxy syndrome has venography of the azygos or hemi-azygos vein during diagnostic right and left cardiac catheterization. [Note: This is an add-on code. Only consider the additional work related to achieving catheter placement and performance of azygos or hemi-azygos venography.]
Description of Procedure (93585)
Insert an end-hole guide catheter through a venous sheath and, with guidewire assistance, into the inferior vena cava (IVC). If present, a second IVC is entered. (Catheter placement is reported separately with the diagnostic cardiac catheterization codes for congenital heart disease.) Perform venography of the IVC with contrast injection to delineate its drainage.
Clinical Example (93586)
An 18-year-old female with complex single-ventricle physiology, who has undergone classic Fontan surgery, has venography of the coronary sinus during diagnostic cardiac catheterization. [Note: This is an add-on code. Only consider the additional work related to achieving catheter placement and performance of coronary sinus venography.]
Description of Procedure (93586)
Insert an end-hole guide catheter through a venous sheath and, with guidewire assistance, to the heart and direct into the coronary sinus. (Catheter placement is reported separately with the diagnostic cardiac catheterization codes for congenital heart disease.) Perform venography of the coronary sinus with contrast injection in the vessel coronary sinus to delineate the course.
Clinical Example (93587)
A 15-year-old female, who previously had Fontan surgery has cyanosis, is discovered with venovenous collaterals has venography performed during diagnostic cardiac catheterization. [Note: This is an add-on code. Only consider the additional work related to achieving catheter placement and performance of venography of venovenous collaterals originating at or above the heart.]
Description of Procedure (93587)
Insert an end-hole guide catheter through a venous sheath and, with guidewire assistance, direct into all portions of the systemic venous pathway(s) draining to the heart from the level of the heart or above. (Catheter placement is reported separately with the diagnostic cardiac catheterization codes for congenital heart disease.) Perform venography with contrast injection to delineate the course and drainage of the venovenous collaterals arising at the level of the heart or above. Repeat the process for any additional venovenous collaterals arising at the level of the heart or above and draining to the heart.
Clinical Example (93588)
A 17-year-old male, who previously had Fontan surgery has cyanosis, is discovered with venovenous collaterals has venography performed during diagnostic cardiac catheterization. [Note: This is an add-on code. Only consider the additional work related to achieving catheter placement and performance of venography of venovenous collaterals originating below the heart.]
Description of Procedure (93588)
Insert an end-hole guide catheter through a venous sheath and, with guidewire assistance, direct into all portions of the systemic venous pathway(s) arising from below the heart. (Catheter placement is reported separately with the diagnostic cardiac catheterization codes for congenital heart disease.) Perform venography with contrast injection to delineate the course and drainage of the venovenous collaterals. Repeat the process for any additional venovenous collaterals arising from below the heart and draining to the heart.
Reference: CPT assistant April 2024