Part B Insider (Multispecialty) Coding Alert

Published on Mon Feb 16, 2004 PDF

Don't send documentation back just because you're not on the same page

The biggest misunderstanding many coders and auditors have when dealing with routine electrocardiograms is the idea that the "separately identifiable written report" must be a separate piece of paper, says David McKenzie, director of reimbursement with the American College of Emergency Physicians in Irving, Texas. This report can be contained within the emergency department treatment record, McKenzie says.

McKenzie cites a June 1996 letter from Terrence Kay, director of physician services at CMS, to ACEP. In the letter, Kay says there's "no reason why a complete written interpretation cannot be recorded within the emergency department treatment records." Kay adds that Medicare officials "fail to see the benefit of a separate piece of paper."

But many coders and auditors believe that ED physicians can't bill for an EKG interpretation unless it's documented on its own page, McKenzie says.

In the 1996 letter, Kay also says that ED physicians' documentation of x-ray interpretations doesn't have to follow American College of Radiology guidelines.