Let’s first look at what a Swan-Ganz catheterization is and how the procedure is performed. The Swan-Ganz catheter is synonymous with a pulmonary artery catheterization. It was named in honor of its inventors who were Jeremy Swan and William Ganz from Cedars-Sinai Medical Center in 1970. It is a flow-directed catheter with a balloon tip that is inserted via an internal jugular or subclavian vein and sometimes the femoral vein. The catheter is then guided by the blood flow into the superior vena cava, the right atrium, right ventricle and then into the pulmonary artery. As the catheter is driven by the blood flow to the pulmonary artery, no imaging is necessarily needed to guide it. This allows the procedure to be done at bedside.
Why is a Swan-Ganz catheterization performed? It measures the hemodynamics to evaluate the heart and lungs particularly for patients with heart failure, shock, post myocardial infarction, pulmonary artery hypertension, pulmonary edema, monitoring after open heart surgery or drug therapy, heart valve disease, and cardiomyopathy.
The Swan-Ganz procedure can measure the pressure of the blood flow through the right side of the heart (right atrium and right ventricle) as well as pressures in the pulmonary artery and the filling pressure or wedge pressure of the left atrium. The pulmonary trunk (artery) arises from the right ventricle and extends upward where it divides into the right and left pulmonary arteries carrying blood toward the lungs. Most catheters have an inflatable balloon at the tip which allows placement into a pulmonary vessel when inflated (wedged) in order to provide indirect measurement of the left atrium pressures. You may see the abbreviations PWP (pulmonary wedge pressure) or PCW (pulmonary capillary wedge). The amount of blood the heart pumps per minute (i.e. cardiac output) is measured during a Swan-Ganz procedure. A sample of blood can be taken during the procedure to provide analysis of oxygen content, saturation and hemoglobin.
A sample description of a Swan-Ganz catheterization procedure:
Right heart catheterization was performed using a/an 7.5 French Edwards Thermodilution VIP Swan-Ganz Catheter advanced to the PCW position through the venous sheath in the right internal jugular vein. Cardiac output was calculated using oxymetric measurements and the Fick principle. The oxygen consumption was assumed to be 125 mL/min/m2. Arterial oxygen saturation was imputed from finger oximetry. At the conclusion of the case, the right heart catheter was secured in place for hemodynamic monitoring in the CCU.
For a diagram of heart chambers and placement of a Swan-Ganz catheter see MedlinePlus at https://medlineplus.gov/ency/imagepages/18087.htm.
What is the difference between a diagnostic right heart catheterization (RHC) and a Swan-Ganz procedure? Since the Swan-Ganz catheterization can measure the pressures in the right side of the heart (right atrium and right ventricle), it is often stated as a right heart catheterization which causes confusion with another procedure – a diagnostic right heart catheterization procedure.
A diagnostic right heart catheterization is performed for diagnostic purposes rather than exclusively for pressure monitoring and measurement purposes. The purpose of the RHC is to identify blockages in the blood vessels supplying the heart or other heart conditions. It includes the study of the right atrium and ventricle, the tricuspid and pulmonic valves, the main pulmonary artery and its branches and the superior and inferior vena cava. Similar to the Swan-Ganz catheterization, the diagnostic right heart catheter is inserted into an artery or vein in the groin, neck or arm. However, contrast is usually injected for angiography to view the vessels and to assist in diagnosing cardiovascular disease. Not unlike the Swan-Ganz, the RHC also obtains pressures including recording intracardiac and intravascular pressures, blood gas testing and cardiac output measurements. Tracings are recorded in the RHC procedure. A RHC is performed by a cardiologist and is done in the cardiac catheterization unit. It is most likely done at the same time as a left heart catheterization. A diagnostic RHC procedure is coded to ICD-10-PCS 4A023N6 – measurement of cardiac sampling and pressure, right heart, percutaneous approach.
Coding Clinic 3rd Quarter 2015, page 39 addresses the coding of Swan-Ganz catheterization. Only the code for placement of the Swan-Ganz device is coded. Unless documented otherwise, the body part value is the pulmonary artery trunk which includes the main pulmonary artery. The assigned code is 02HP32Z – insertion monitoring device, pulmonary, percutaneous approach. If there is ongoing monitoring via a previously placed Swan-Ganz catheter, monitoring of arterial pressure, pulmonary, percutaneous approach (4A133B3) and/or monitoring of cardiac output, percutaneous approach (4A1239Z) may be coded.
ICD-10-PCS guidelines state the root operation is based on the objective of the procedure. If we look at the root operations assigned for Swan-Ganz and diagnostic right heart catheterizations, it may provide some additional understanding of the distinction between the two procedures. The root operation for a diagnostic right heart catheterization is “Measurement” which is determining the level of a physiological or physical function at a point in time. The objection of the RHC is to diagnosis the current function of the right heart vessels.
The root operation for the Swan-Ganz catheterization is “Insertion” which is putting in a nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part. The objective of the insertion of the Swan-Ganz catheter is to monitor the hemodynamics of the heart and lung when placed in its final position within the pulmonary trunk. The catheter is simply passing through the right atrium and right ventricle on its way to the pulmonary artery but monitoring of pressures are taken along the course.
Here are some questions to ask yourself when you’re unclear whether a Swan-Ganz catheterization or diagnostic right heart catheterization (RHC) is being performed:
Documentation Likely Procedure
Coronary artery disease diagnosed RHC
End point of the catheterization is in the pulmonary trunk Swan-Ganz
The procedure is done at bedside Swan-Ganz
PCW or PWP is mentioned Swan-Ganz
The catheter end point is within the right heart chambers RHC
A Swan-Ganz device is the type of catheter used Swan-Ganz
Flow-directed catheter is documented Swan- Ganz
Critically ill patient to monitor hemodynamics Swan-Ganz
A left heart catheterization is also performed RHC
No fluoroscopy or imaging done Swan-Ganz
Diagnosis of tricuspid insufficiency made RHC
It is important to determine the objective of the catheterization – whether the procedure is for diagnostic purposes or monitoring purposes. The diagnostic right heart catheterization is a non-OR procedure which can impact the DRG. If you are unsure regarding whether the procedure is a Swan-Ganz catheterization or a diagnostic right heart catheterization, seek advice from the folks in the cardiac catheterization lab or your coding supervisor/manager.