by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC
Question:
I have read a few responses from prior Dr. Z questions regarding what documentation is needed to support IVUS CPT 97928. I’m having a little trouble deciphering if this documentation supports that CPT code.
Documentation within separate H&P includes a paragraph that IVUS was used to assess vessel size and degree of calcification and was followed by placement of Frontier stent and Euphora for optimum stent apposition.
The peak and mean aortic valve gradients and measurements are included within an additional cath procedure note, as well as pressure measurements for multiple LV and AO pressures. The hemodynamic procedure report generated during cath includes Euphora was inflated in LAD followed by documented times for insertion of ultrasound catheter with IVUS run started, run completed, IVUS catheter out times.
Is this combined documentation between notes enough to support physician billing of CPT 92978-26-LD (please note CPTs 92941 and 93458 were also billed)?
Answer:
IVUS can be used to evaluate for calcium, for size, for stent deployment, etc. Sounds like that was done here, but does not state what vessel it was done in. If you know that, you have a code.
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