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Wiki Detailed documentation in Cardiac Op Note

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KoBee

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I reached out to a provider telling him to document the injection and contrast when doing a left ventriculography during heart cath. In order to do a left ventriculography the use of contrast is needed.

If we would get audit for using 93458 and mentioned in his report that he did a left ventriculography but no injection or contrast is mentioned, does it matter? He is stating regardless of whether contrast is mentioned in the report in any case it doesn't matter because it's not relevant to the current situation.


HELP please :/
 
Dear Dr. I-Know-Things:

I have been retained by your former patient, who is suing you for malpractice. Apparently, you performed a left ventriculopathy without contrast. Would you like to talk, or just write my client a blank check?

Sincerely,

Mr. If-It-Wasnt-Documented-It-Wasnt-Done, Attorney at Law

cc: Medical Board of Your State
 
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