Wiki basic cardiac monitoring question.....

[Rncoder]

I code for an ER... if a patient comes in with chestpain or another symptom that would lead the nurse to put the patient on a cardiac monitor...and the nurse documents that the monitor was on and notesd the heart rhythm....but, the doctor did not specifically order "cardiac monitoring" can i still charge that a cardiac monitor was on (for those that use protocaols, this would be that no protocol was ordered as well ). thanks. I LOVE having all these questions i have had answered. You guys are so smart. Thanks for putting up with my easy questions!!

 

[kevbshields]

For whom are you coding--physician or facility?

Sounds like facility, but I don't want to be presumptive.

 

[Rncoder]

I do remote coding for ER's. So i am coding for the Hospital based ER after i ready the medical recors.

 

[kevbshields]

Alright, so I can't give you a yes or no answer--mostly because I'm not sure of your facilities' policy.

From a facility-fee standpoint, you may code for the tracing--as long as the coding policies don't state that an order (or protocol) is necessary. Personally, I know that based on the presenting sign/symptoms, the nurse's actions of attaching the card. monitor do fit some sort of protocol, though perhaps not a written/stated one. Nevertheless, I'd query someone "in the know" on the actual coding policy in instances like this.

For the physician, unless he/she interprets something (and documents that clearly in the record), there's nothing to code/bill outside the EM service.

I hope this answers your question.