Ask Dr. Z

For professional coding, may the hospital cardiac cath or procedure log be used in conjunction with the provider's dictated procedure note to code for services performed? Example, if the provider provides all the findings for angiography and heart cath along with details for any PCI performed in their dictated procedure note, but they don't include details such as catheter placement for coronary angiography and heart catheterization, can the log be used to confirm catheter placement and once confirmed can coding be assigned for these services using this information? The log is signed by the provider who performed the service.

Lastly, if the log can't be used to support catheter placement, is provider documentation of type of catheter used for "diagnostic exam", "coronary angiography", or "left ventriculogram" enough to support coding coronary angiography and heart cath without the provider detailing placement of the catheter in the left ventricle for heart cath or a coronary artery or stating "selective" coronary angiography was performed?