Wiki DOCUMENTION IN CATH LAB NOTES

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mitzimarie2001@yahoo.com

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I need some clarification on the documentation required in Cath Lab Notes to support the CPT codes provided. This cardiologist lists "Procedures Performed." Then she provides the "Procedure Details." Sometimes it doesn't look like the details match the list. I am still trying to get used to this particular cardiologist. I may be missing something in the details. For example, #7 in the "Procedures Performed" shows Aortic root and abdominal aortogram. The paragraph in the procedure details describing the left heart Cath does say "Aortic root and ascending aortogram was done using the same catheter," but I don't see the abdominal aortogram described anywhere. I do see Right External Iliac and Left Common Iliac Findings at the end of the report. Can someone please help me tie this together? I am new at reading Cath Lab Reports. Below are the Cath Lab Notes.

1724269485377.png

The codes she provided are:
93458-26
76937-26-XU
93567-XU
36245-XU
75625-26-XU
75710-26-XU
99152
 
I agree with the LHC code, and for 93567, the doctor after the catheterization of the left ventricle pulls the catheter back into the aorta just above the aortic valve and injects again to see if there is any regurgitation of the aortic valve. For 75625, there is no documentation to support that code. For the 75710, I think that was for the closure device and is not billable.
Good luck,
Jim
 
Many thanks for your help, Jim. If I may, I'd like to ask another question regarding documentation (in general).

Certain procedure codes require specific ICD-10-CM codes that support medical necessity. For instance, 75625 is a code that requires specific diagnosis codes. One of my cardiologists rarely bills for 75625 when performing heart caths. This cardiologist, however, pretty much always tries to bill for it. On the occasion that it is a legit procedure, she never provides any other diagnosis codes, other than the indication for the heart cath (for example, unstable angina). Those cardiac codes are not on the acceptable list of diagnosis codes supporting medical necessity for 75625. My question: to what lengths am I allowed to go, to try to find a suitable diagnosis for 75625? Does it have to be included as part of the report? We have told her repeatedly to provide proper diagnosis codes for each procedure, but she will not do it.

Mitzi
 
My experience is if the dx. code is not correct for the procedure; the third-party payer will reject it. It may say that 75625 "requires a required diagnosis code". Then they may not pay the full amount because of the rejection. Also, if it's not in the report, it didn't happen. You have to have documentation to support the code/ charges.
HTH,
Jim
 
Thanks for your reply, Jim.
"if it's not in the report, it didn't happen. You have to have documentation to support the code/ charges."
That's what I needed to know. She expects us to search past medical records to see if there are any diagnosis codes that may support medical necessity for the current procedure.

Appreciate your help.
Mitzi
 
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