Cardiology Coding Alert

Question: Can you please help me understand the requirements for billing device interrogations in the hospital setting? I have always been told that we can’t bill any interrogations without documentation that is separate from the note, like having the printed information from the interrogation in the patient’s file that supports the actual interrogation being completed. I was recently told that I can bill out device interrogations in the hospital setting without this information. I need documentation to make the case to my cardiologist that we cannot bill unless the device information is in the patient’s file. Can anyone point me in the right direction for supporting guidelines?

North Dakota Subscriber

Answer: The professional component of a diagnostic procedure furnished to a beneficiary in a hospital includes an interpretation and written report for inclusion in the beneficiary’s medical record maintained by the hospital. (See Medicare law 42 CFR 415.120(a).) CMS requires a report to be complete, documented similarly to that of a specialist in the field, and consistent with the treatment rendered. CMS also differentiates between an interpretation with report from a simple review. An interpretation with report must include findings, relevant clinical issues, and comparative data if available. CPT® states there must be a separate, signed, written, and retrievable report.”