Wiki Cardiac cath documentation for moderate conscious sedation

[heartyoga]

We always get a denial for moderate conscious sedation from United Healthcare. I attended a coding seminar available from their website. https://cx.uhc.com/content/uhc-provider/uhconair/en/coding.html
and they mentioned that the documentation should state there is an independent trained observer.

An example of our cath documentation as ff:
Indications:
Recurrent chest pain despite medical therapy
Dyspnea
Abnormal stress test with ischemia at inferoapex by nuclear scan
Hyperlipidemia
Abnormal EKG with new T-wave inversion during Lexiscan infusion

Informed consent was obtained from the patient. Patient was brought to the cardiac cath lab and prepared according to protocol. Right radial area was infiltrated with 1% Lidocaine, subsequently right radial artery was cannulated using modified Seldinger technique. this was accomplished in one attempt. Left heart cath, selective left and right coronary angiographies were done. At the end of the study, all guidewires, catheters and sheaths were pulled out. TR band was applied for 2 hours. No complication was encountered.

Procedures performed:
1. Moderate conscious sedation with face to face direct supervision for the first 30 minutes.
2.left heart catheterization
3. Selective left and right coronary angiographies
4. Right radial arteriotomy

Findings;
Hemodynamics:
...
(it has more not typing it for now - not related to my question.)

Any suggestions on how this could be improved for UHC to pay?

Thanks!

 

[SharonCollachi]

I would say "prepared according to protocol" doesn't say what was done - were they given propofol? versed? morphine? IV? IM? Subcu?

And "face-to-face direct supervision" does not equal "independent trained observer".

 

[Jim Pawloski]

Need to know how much sedation was given. Also, propofol is usually given with anesthesia, but that depends on the institution protocol.
HTH,
Jim Pawloski, CIRCC

 

[heartyoga]

Thanks Sharon and Jim !