Wiki 93545 and 93543 LHC Injections

[klapierre]

When performing a left heart catheterization does the physician need to document the injection procedure in the procedure details? Our physician typically discusses the injection (93543) for the left ventricular angiography (93555), but only documents the imaging S & I for the coronary angiography (93556), without documenting the injection procedure (93545). Do they need to document both injection procedures?

 

[sbicknell]

Yes, in the procedure report he needs to state something like "right coronary selectively engaged and injected. Left coronary selectively engaged with injection" or he can combine the statement when he does both.

He needs to state what coronary vessel he was in, that he injected and the result of what those injections showed. The interp supports only the 93555-93556 with nothing to support the 93539-93545

I know some feel that "well if he is giving the interp of the injection then he must have done the injection". I don't subscribe to that assumption. And I don't want to argue the point with an external auditor.

Bottom line is the documentation must clearly state and support the services performed, coded and billed