Why do cath lab and high-cost procedures need separate billing attention?
Because these claims are short but expensive. A handful of implants and supplies concentrate the value, and a single denied item can weigh as much as dozens of per diems. The cath lab combines three risks: frequent urgency, a change of approach during the procedure itself, and high-value devices with their own authorization and traceability rules.
The weight of these items shows up in industry revenue. In 2025, implants, supplies and drugs made up 42.85% of gross revenue at hospitals of the National Association of Private Hospitals (Associação Nacional de Hospitais Privados, Anahp), and implants alone rose from 7.61% in 2024 to 8.68% [1]. On the cost side, implants also accounted for 8.68% of total expenses in 2025, according to the same publication [1].
Cath lab billing is an application of hospital billing. The steps are the same; what changes is the level of proof required for each high-value item. The general implant rules are in the guide OPME billing.
What to check in the authorization before the procedure
Authorization for an elective high-cost procedure must cover the main procedure, the planned implants and the care setting (inpatient or outpatient). Lei 9.656/1998 (Health Plans Act) requires the contract between hospital and health plan (operadora) to state which acts require authorization, and Normative Resolution (RN) 503/2022 of the National Supplementary Health Agency (Agência Nacional de Saúde Suplementar, ANS) asks the contract to set out the routine, responsibilities and response time [10][11].
Maximum timeframes for care come from RN 566/2022. For cath lab billing, three lines matter [2]:
| Situation | Maximum timeframe (RN 566/2022) | What to check on the claim |
|---|---|---|
| High-complexity procedure (PAC) | 21 business days | Whether the procedure is classified as PAC in the ANS coverage list (Rol) and whether the authorization covers the date performed |
| Elective admission | 21 business days | Admission and implant authorizations linked to the same request |
| Urgent and emergency care | Immediate | Clinical record of urgency and notice to the health plan per the contract |
RN 623/2024 adds to the rule: when the reply to the patient is not immediate, the health plan has up to 10 business days for PAC and elective admissions, and the shorter RN 566/2022 timeframe always prevails [3]. A denial must be in writing and justified [3].
Check coverage before scheduling, too. Some interventional cardiology procedures have a Utilization Guideline (DUT, Diretriz de Utilização) in Annex II of the Rol, such as implantable cardioverter-defibrillators (DUT 35), pacemakers (DUTs 40 to 42) and transcatheter aortic valve implantation (DUT 143) [9]. In the Annex II index, coronary angioplasty does not appear with its own DUT [9]. Where a DUT applies, the medical report must show the criterion met, as explained in the guide Utilization Guidelines (DUT).
Implants in the cath lab: who chooses, and what happens in a disagreement
The attending physician defines the implant's specifications; the health plan can question them, but there is a set procedure for that. Resolution 2.318/2022 of the Federal Council of Medicine (Conselho Federal de Medicina, CFM) gives the attending physician the task of defining the implant's and instruments' characteristics, requires a clinical justification and prohibits demanding an exclusive supplier or brand, unless a single manufacturer is justified [4].
If the health plan rejects the device, the physician must offer at least three brands from different manufacturers registered with Anvisa (Brazil's health regulatory agency) [4]. If the disagreement persists, the resolution provides for a specialist chosen by mutual agreement within five business days; in urgent and emergency cases, arbitration happens after the procedure [4].
On the ANS side, RN 424/2017 regulates the medical board (junta médica) for disagreements over procedures and implants, within RN 566/2022 timeframes, and excludes urgent and emergency cases from that process [5]. ANS Technical Opinion 24/2021 notes that implant coverage requires a device registered with Anvisa and linked to the surgical procedure, and excludes experimental use [6]. Details are in the guides OPME authorization and Medical boards.
The procedure changed in the room: now what?
When the approach changes during the procedure, the authorization has to follow the change. This is the classic cath lab case: the diagnostic catheterization reveals a lesion, and the physician performs angioplasty in the same session, with a stent that was not planned.
In urgent cases, Lei 9.656/1998 guarantees coverage of care [10], and any disagreement over the implant goes to arbitration afterward under CFM Resolution 2.318/2022 [4]. In elective procedures, the contract sets the path: how and how quickly to request a supplementary authorization, and which document proves the need. Without that written rule, the unauthorized stent tends to be denied as a charge that requires prior authorization (TUSS message 1818) [8].
In practice, three records support the claim: the procedure report describing the findings, the segments treated and the quantity of each device; the justification for the change in approach; and the protocol number of the supplementary request to the health plan. The guide Urgent and emergency care covers coverage for immediate care.
How do implants go on the TISS claim?
In the TISS standard (Troca de Informação de Saúde Suplementar, Brazil's health plan data exchange standard), implants go on the claim through the Other Expenses Attachment, which accompanies the SP/SADT form (outpatient services and diagnostic tests) or the inpatient summary and itemizes gases, drugs, supplies, implants, fees, rentals and per diems [7]. The authorization request follows a different route: the OPME Request Attachment, linked to the admission or SP/SADT request [7].
On both attachments, the item is identified by its code in table 19 of TUSS (Terminologia Unificada da Saúde Suplementar, Brazil's unified coding terminology for private health care), the table for supplies and implants, which is sourced from Anvisa registrations [7]. A code mismatch between request and claim is one of the easiest failures to avoid.
The label and the invoice prove use
Proof that the implant was used in the patient is the traceability label, with the lot number, together with the invoice. CFM Resolution 2.318/2022 requires labels to be attached to the medical record and, in its annex, provides for five copies per implantable device: medical record (mandatory), report given to the patient, sales invoice in private health care, supplier and surgeon [4].
The denial messages in TUSS table 38 show where the health plan checks [8]:
| Message (TUSS 38) | What it indicates | Proof that prevents it |
|---|---|---|
| 3255 | Item without the supplier's invoice | Invoice attached, with the same item and lot |
| 1818 | Procedure that requires prior authorization | Implant authorization number or supplementary request protocol |
| 3197 | Item not used | Label in the medical record and report listing the device |
| 3190 | Item quantity incompatible with the procedure | Report with the number of stents or catheters per segment |
| 3211 | Item included in the negotiated bundle | Contract with the bundle composition |
| 3263 | Implant labels (effective 12/01/2025) | Complete, legible labels in the medical record |
The full list and appeal strategies are in the guide OPME denials. Code descriptions are translated summaries; TUSS exists only in Portuguese.
Bundle or itemized claim: what changes in billing?
Under a bundle (pacote), the hospital charges a single price for the procedure; under an itemized claim (conta aberta), it charges item by item. In the cath lab, both models coexist, and the risk lies at the border between them. Anahp's 2025 contracting manual describes the bundle as a single price with itemized detail and addresses including drugs and implants in its composition [12].
What the contract must state, and billing must check, is what is inside the bundle and what is charged separately: number of stents included, catheters and guidewires, contrast, room and recovery time, per diems and physician fees. An item billed separately when it was already included triggers message 3211 (item included in the negotiated bundle) [8]. The reverse also happens: an extra stent left unbilled for lack of a clear rule is lost revenue. See the guide Hospital bundles.
Five checks on a cath lab claim
Before submission, a cath lab claim goes through five checks in sequence:
See the checks as a table
| Check | What to verify | Denial it prevents (TUSS 38) |
|---|---|---|
| 1. Authorization and coverage | Valid authorization number for the procedure performed, utilization guideline (DUT) met, urgency recorded | 2206 |
| 2. Implant ordered vs. authorized | Same brand, model, quantity and TUSS table 19 code in the request and the claim | 2206, 2210 |
| 3. Procedure report | Findings, segments treated, devices used and reason for any change in approach | 2207, 2210 |
| 4. Labels and invoice | Label in the medical record and same lot number as the invoice | 2203, 3255, 3263 |
| 5. Bundle vs. itemized claim | Items inside and outside the bundle per the contract | 2211 |
- Authorization and coverage: valid authorization number for the procedure performed, DUT met where applicable, and urgency recorded if relevant.
- Implant ordered vs. authorized: same brand, model, quantity and table 19 code in the request and the claim.
- Procedure report: findings, segments treated, devices used and justification for any change in approach.
- Labels and invoice: label in the medical record, lot number matching the invoice, invoice attached.
- Bundle vs. itemized claim: items inside and outside the bundle per the contract; team physician fees entered per the rules in the guide Physician fees on the hospital claim.
Consumables (sheaths, guidewires, contrast) follow the price rules of the reference schedule in the contract, covered in the guide Supplies and drug denials.
What we see in operations
At Accrua, cath lab claims are read with close attention to the few items that concentrate the value: OPME (implants and special devices), supplies and drugs. Before submission, Accrua OS checks whether the procedure performed is the one authorized, whether each device is on the Other Expenses Annex with its TUSS table 19 code and whether the label in the medical record matches the invoice.
When the procedure changes in the room, the supplementary authorization task reaches the team with what the health plan requires, instead of showing up later as a denial. If the contract sets a bundle, the claim is checked against what is inside and outside it. Changing an item that affects the value is a person's decision.
When the denial arrives, the agent drafts the appeal with the label, the invoice and the procedure report. Because these are high-value claims, the risk also hits cash: Receita Garantida puts the value of eligible production into the hospital's account, and Accrua takes on the risk of eligible denials.
Where to start
- Pull cath lab claims from the last 6 to 12 months and break down denials by table 38 message and by health plan.
- Review contracts with the main health plans and confirm what each bundle includes and how to request a supplementary authorization when the approach changes.
- Standardize the procedure report with required fields for segments treated, devices, quantities and lot.
- Set up the label x invoice x TUSS code check before closing every claim with implants.
- Define the urgent-care workflow: who notifies the health plan, how quickly and with what clinical record.