Ask Dr. Z

Patient with TOF and pulmonary atresia s/p BT shunt comes in for evaluation of shunt and pulmonary arteries as well as embolization of collaterals. The embolizations are straightforward, but it does not seem that there was any heart cath performed. No documentation of catheter placement in any heart chamber and no pressures recorded. The only reference is in the title of the report, which says, "Left heart catheterization." Catheter travel documented is from left femoral artery access to aorta, innominate, subclavian, BT shunt, and ultimately pulmonary arteries as well as collaterals branching from aorta. Since the coding is very dependent on whether or not a heart cath was performed, what would you recommend if it turns out that it was not performed?