When my doctor performs a diagnostic angiogram or interventional procedure such as embolization, what does he need to document?
For a diagnostic angiogram, the doctor should document where he gained access (and whether he used ultrasound guidance according to the guidelines for code 76937) for that access. Then he needs to document where he maneuvered the catheter. Each vessel catheterized should be specifically and precisely documented. Language such as “several branches” or “a few branches” is not sufficient. The vessels where angiograms were taken should be documented and findings from those angiograms must be reported. If a diagnostic angiogram is performed at the same session as an intervention, the doctor should document that the decision to intervene was made based on the diagnostic angiogram (if it was), or if the decision to intervene had already been made, the doctor must document why this angiogram was necessary. When an intervention is performed, the location of that intervention and the reason it is being performed should be documented as well as the technique. If the coder or auditor cannot determine from the documentation what was actually performed, they cannot code appropriately, and reimbursement will be lost.