Wiki Cardio Cath Injection Documentation Requirement


Carlsbad, CA
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The technicians print an automatated cath report from the cath lab and some of the cardiologist would like us to code directly from that report for injection codes 93544 & 93545 instead of these injections being dictated in their procedure notes. Our outside auditor states that since there are no specific format guidelines for procedures it is okay to code from this tech generated report as long as there is clear information in this record that injections were performed. Our concept is that this is a basic documentation guideline issue and since our guidelines state what isn't documented by the physician didn't happen then we are in disagreement. This is not a shared visit or incident to situation. Does anyone know where I may find a guideline that states ithe physician must document the entire procedure?
Here's a suggestion: have the physicians (if they want coders to use the Tech Report/Nurse Report, etc) to sign that report and it can be used for coding purposes--by my understanding. You might also have them refer to that report in their dictations. I believe either would serve the purposes of solving the "disagreement" you speak of.

As for where there's a guideline, I'm not sure you really need one. From a compliance perspective I can understand the concerns, but if you're coding for the professional component, it is concluded that you would only be utilized records that relate to the professional record (that created by and maintained by the physician).

However, you may wish to visit the ACR website at or the Society for Interventional Radiologists because they may have something stated in terms of clinical and medical practice guidelines--although I doubt that's what you're asking for in this situation. If the physician signs a record--even when someone else may be acting as his/her scribe--that record is considered his/her formal record (or at least part and parcel to the record).

Just my suggestions. I believe your auditor is being prudent, but not very visionary.

Good luck.
Thank you for responding . Still have a few questions...Is your answer the same if you are only performing physician based coding and not coding for the hospital? In these cases the technician is not acting as a scribe and is an employee of the hospital not the physician's office. It is my understanding that a scribe is employed by the physician. Do you know if this is correct?
It is not longer a "technician's" record if the physician signs on the bottom; by signing, the physician is attesting that what is written is correct.

To my knowledge it would make no difference, if you have that signature.

If anyone has information that recommends something different, please post it here. In the meantime, I'll poke around to see what I can obtain in terms of commentary.

Good luck!
I was told by our CMD for Noridian that the technichian reports are NOT acceptable documentation for coding/billing.

Bea Olsen, CPC, CCAT
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Those reports are not suitable--if they're unreviewed by the physician. However, just as with an "incident to" scenario, if the physician reviews and agrees or adds addendums to the material, it is therefore his/her signature that makes the difference between a viable note versus a useless one.

In and of themselves, the notes cannot be considered "billing material;" used in conjunction with the actual physician operative/procedure report, I see no reason those documents would not serve to substantiate the service.
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