Does procedure 93318 require a separate report?

OliviaPrice

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The question has come of as to whether or not the cardiologist needs to dictate a separate report for an Intraoperative TEE. Currently the surgeons notes in his dictation that an Intraoperative TEE was done, they do not however included who conducted the TEE. We are wondering if the cardiologist that performed the TEE should dictate a separate note?
 

deeva456

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Most definitely. The cardiologist who performs the TEE must dictate a separate report to report his/her findings. It falls under the golden rule of coding: If it wasnt dictated, it wasnt done. Even if the primary surgeon mentions in his report that your doctor performed an introperative TEE, a separate report is required.
 
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