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?