Wiki DX code from EKG interpretation

[saj402]

I am auditing some ED records and struggling if this is appropriate or not. Patients that come in with chest pain and the provider orders an EKG. There is a signed machine-generated EKG tracing in the record. It is appropriate to assign the diagnosis, such as Incomplete RBBB or abnormal ECG, from the machine-generated report? The provider's final diagnosis might only be "Chest pain". thanks.

 

[devinmajor14]

From my experience... I would only code the Dr's final dx.

 

[Anitha Lingala]

Yes, code for the chest pain only.

 

[CactusCoder]

I am auditing some ED records and struggling if this is appropriate or not. Patients that come in with chest pain and the provider orders an EKG. There is a signed machine-generated EKG tracing in the record. It is appropriate to assign the diagnosis, such as Incomplete RBBB or abnormal ECG, from the machine-generated report? The provider's final diagnosis might only be "Chest pain". thanks.

In my experience, you can assign a dx from the provider's interpretation. That is, the provider wrote "RBBB". You cannot assign RBBB from your own interpretation of the waveforms.

However, I would think chest pain would be a sufficient dx to support an EKG for any payer.