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Heart Cath documentation

  1. #1
    Default Heart Cath documentation
    Medical Coding Books
    Hi I was hoping maybe I can get some opinions from other coders regarding documention for a heart catheterization.

    My physician is documenting that he is performing a left ventriculography in his report,however my physician is not stating how he injects the dye or or how the actual procedure is performed when he does this part of the procedure.

    My questions is would you code for 93543, and does anyone know were I can find a site or information that can give me some direction on what requirements must be on a dictated report to show my phisicians.

  2. #2
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    Birmingham, Alabama
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    Quote Originally Posted by yvette31 View Post
    Hi I was hoping maybe I can get some opinions from other coders regarding documention for a heart catheterization.

    My physician is documenting that he is performing a left ventriculography in his report,however my physician is not stating how he injects the dye or or how the actual procedure is performed when he does this part of the procedure.

    My questions is would you code for 93543, and does anyone know were I can find a site or information that can give me some direction on what requirements must be on a dictated report to show my phisicians.
    Yvette,
    If you look up cpt 93543 and go to the guidelines at the beginning of the section, that could answer most of your question.

    IMO, the physician only needs to document that the procedure was done (93543), he does not need to necessarily document the method of injection or the dye used(although that can be very helpful). He also should provide an interpretation (93555) for me to bill. Just getting pressures in the Left Ventricle does not equal a ventriculography.

    HTH
    Danny L. Peoples
    CIRCC,CPC

  3. #3
    Default
    Quote Originally Posted by yvette31 View Post
    Hi I was hoping maybe I can get some opinions from other coders regarding documention for a heart catheterization.

    My physician is documenting that he is performing a left ventriculography in his report,however my physician is not stating how he injects the dye or or how the actual procedure is performed when he does this part of the procedure.

    My questions is would you code for 93543, and does anyone know were I can find a site or information that can give me some direction on what requirements must be on a dictated report to show my phisicians.
    My opinion is that the dr. should be saying, that a catheter was placed in the left ventricle and contrast was injected by either hand or by power injection. If he doesn't say it, it didn't happen, and you do not code it.

    HTH,
    Jim Pawloski, CIRCC

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