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cardiac cath-left cardiac cath

  1. Default cardiac cath-left cardiac cath
    Medical Coding Books
    When a left cardiac cath is performed with coronary and ventricular angiograms , is it necessary to have the actual contrast injection stated in the body of the report for both angios? If yes, can somebody direct me to the actual place where this rule written? Thanx

  2. #2
    Our cathlab docs typically set up their dictation in sections, where they specifically reference each vessel that they imaged and then have a seperate section for their ventriculogram results. Since you wouldn't be able to do a coronary angio or ventriculogram without contrast, I am thinking the best answer to you question would be "no" you don't have to state the contrast was injected, stating the procedures were performed may be sufficient (you can't have one without the other situation) but you would perhaps want to be sure that you have evidence that the coronary arteries were selectively engaged and that some reference was made to the results of the ventriculogram. Perhaps the one "back up" that we have in our dictation set up as well is that the doctors dictate the total contrast utilized during the procedure.

    Here is a mock up of the style we use
    PROCEDURE: Left Heart Catheterization with Coronary Angiogram and Left Ventriculogram


    Left Main: the LMCA is normal
    LAD: LAD has 50% to at most 60% narrrowing at the mid LAD
    Left Circumflex: Normal
    RCA: 20% narrowing in the proximal to midportion of the RCA

    Left Ventriculogram: There is no mitral regurgitation. LVEDP is 27.

    Total Contrast 320 ml of Optipray 350. Fluoro 7.0 minutes


    Hope this was helpful.
    Last edited by jtuominen; 04-17-2009 at 11:24 AM.

  3. Default
    Thank you, it was helpful

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