Ask Dr. Z

Patient with AMI taken to lab. Diagnostic cardiac cath (93455) was performed, and upon trying to intervene on the culprit lesion the physician was unsuccessful in crossing the lesion and the procedure was discontinued. The physician does not document the intended procedure (i.e., angioplasty alone, angioplasty with stent, angioplasty with atherectomy, or all three). In the absence of clear documentation of the intended PCI procedure, considering code 92941 requires combination of angioplasty with either stent and/or atherectomy, should we report code 92920-74? Being conservative rather than assuming without documentation that a stent and/or atherectomy was planned?