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Documentation of Cerebral Angiography

Date: May 6, 2014

Question:

We have a question concerning documentation. Is it enough to charge for fluoroscopy during a VAD insertion when the fluoroscopy is only documented in the list of procedures and not mentioned in the body of the operative report? Also, is the following sufficient to charge? Again, the actual selective vessels are listed at the top of the report, with the “select the above mentioned vessels” in the body of the report. The findings are documented. We do believe this documentation is sufficient, but I want to ensure it would hold up on an audit. "Vessels catheterized: 1) Right common carotid artery. 2) Right vertebral artery. Technique: Cerebral angiogram performed. Next, using a micro-stick singlewall puncture, the right common femoral artery was accessed and a 5 French sheath placed with a modified Seldinger technique. A 5 French DAV catheter and 035 Glidewire were navigated under fluoroscopic guidance to select the above-mentioned vessels. Multiple angiographic images were obtained. At the end of the procedure, all catheters and wires were removed."

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