Documentation Is Key to Pay Up for Cardiology Procedures
Published on Wed Nov 01, 2000
Cardiology billers should always make sure the procedures listed at the top of an operative report correspond to the description of the operative session in the procedure notes. Sometimes, cardiologists list procedures performed at the top of the op note, but the cardiologists notes make no mention of the procedure. Alternatively, the procedure notes may describe a procedure that hasnt been listed at the top. Both examples will cause confusion for the person coding the procedures.
The first scenario is far more serious if a procedure hasnt been described, it is as though it hasnt been performed because there is no record of it in the patients chart. When coders spot this sort of discrepancy, they should talk to the cardiologist involved to determine if the procedures actually were performed. If the listed procedures were performed, the cardiologist should be asked to write an addendum describing the procedures in question before the claim is submitted.
Cardiologists are prone to omit such critical data inadvertently because the services they perform often involve several procedures and associated codes. For example, intervention procedures such as percutaneous transluminal coronary angioplasties (PTCAs), stents or atherectomies usually involve cardiac catheterization and associated injection procedures as well as supervision and interpretation (S&I), and may also include injections of thrombolytics or nitroglycerin. Such procedures are often bundled, but the cardiologist may list them separately with the expectation of reimbursement.
In the following case study, the cardiologist lists two interventions, a cardiac catheterization (and its associated injection and S&I procedures) and a Reopro injection. The procedure notes, however, tell a different tale.
Operative Report
Date of Service: 8/17/00 10:00 a.m.
Procedures:
1. Left heart catheterization
2. Left ventriculography
3. Selective coronary angiography
4. Percutaneous transluminal coronary angioplasty of right coronary artery (RCA) stenosis
5. Deployment of stent into RCA stenosis
6. Administration of Reopro in cath lab to dissolve blood clot
Indications: Increasing angina, shortness of breath, abnormal stress test indicating myocardial disease.
Description of Procedure: Informed consent was obtained and patient was brought to cath lab ... After satisfactory local anesthesia was achieved, the right femoral artery was cannulated ... and a 6-French arterial sheath was placed and flushed. Left heart catheterization, left ventriculography and selective coronary angiography were then performed ... At the end of angiography, catheter was removed, sheath was flushed and findings were reviewed. Left ventriculography demonstrated a mildly enlarged left ventricle with global hypokinesis and severe left ventricular dysfunction. Left ventricular ejection fraction is calculated at 30 percent. Selective coronary angiography demonstrated right coronary artery damage. The RCA gave rise to a posterior descending (coronary) artery (PDA) and posterolateral left ventricular branches. The mid-portion of the right coronary artery had a long tubular stenosis. The mid-portion of this tubular stenosis has [...]
