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Did my doc perform a LHC?

  1. #1
    Question Did my doc perform a LHC?
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    I have a doc that "sometimes" notes the pressures in the left ventricle and/or notes that he did the "pullback across the aortic gradient." This lets me know he TRULEY performed the Left Heart Cath.

    But what if he just simply states that there is normal LV systolic function... Is this part of the selective angio or does it mean he did the left heart cath?? He has no other indication of performing a left heart cath. I believe I would just code for the selective angio that he performed. Can someone help me?


    Brandy Edmondson, CPC

  2. #2
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    Quote Originally Posted by brandyleigh23@hotmail.com View Post
    I have a doc that "sometimes" notes the pressures in the left ventricle and/or notes that he did the "pullback across the aortic gradient." This lets me know he TRULEY performed the Left Heart Cath.

    But what if he just simply states that there is normal LV systolic function... Is this part of the selective angio or does it mean he did the left heart cath?? He has no other indication of performing a left heart cath. I believe I would just code for the selective angio that he performed. Can someone help me?


    Brandy Edmondson, CPC

    I would trust (and I agree with) your gut instinct. Without clear documentation of pressures or selection in the LV, I would just code the angios w/o LHC. However, it is certainly worth some effort to clarify this with your doc.

    HTH
    Danny L. Peoples
    CIRCC,CPC

  3. Default
    I agree with Danny, if it is not clearly documented it did not happen. As he said, query your physician, he may need to amend his dictation.

    If you do not generally query your docs be careful with your presentation to him so not to appear to be second guessing, maybe present it as a "learning" session for you. If you can establish good a positive response from this query it will make each query easier and result in a good coding relationship between you and your docs.

  4. #4
    Thumbs up
    Thank you both so much! I have only been coding Cardiology for 4 months and I have had a few of these come through. I want to confront him with it, but like you said I need to really think about how I am coming across. I don't want to seem like a "know it all" or seem as though don't know what I am talking about either. Thanks again

    Brandy Edmondson, CPC

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