Please note this question was answered in 2012. The coding advice may or may not be outdated.
Documentation
Date: May 2, 2012
Question:
Dr. Z, In the description of Procedure portion of a Left Heart Cath an Abdominal Aortogram with runoff is described. But that's it. There is no description of the renals or legs. I've requested an addendum asking for the findings for the Abdominal Aortogram and runoff as well as the reason for it (medical necessity). In his addendum it only included the "uncontrolled hypertension" as the reason. For the purpose of any potential future audits, shouldn't there be 'findings' of the abdominal aortogram and runoff describing the condition of the renals, abdominal aorta, and legs?
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