EKG 93010 Documentation

fredcpc

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To code the professional part of a EKG in the office, what wording is required? Does is need to be stated as "interpreted by me?" or can the physician write on the Rad strip the he agrees with the machines interpretation and then sign it? :confused:

If it is the second choice, then I can bill a 93010.
 

Cyndi113

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Our providers just sign the EKG, electronically. When the EKG is scanned into EMR, it reads as confirmed by with electronic signature by the provider.
 

fredcpc

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Ekg 93010

Cyndi -- So when you providers sign the EKG electronically, what your is code of choice? I am guessing 93010. Also, do you scan in the whole EKG strip?

Thank you for your input on this.:D
 

fredcpc

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EKG 93010 documentation

Here is the scenario that is cause for thought and feedback....

Medicare patient
Sex; female
Pain Scale: 4
Pain location: Chest
Surg Hx: Hysterectomy

Allergies: Epinephrine, Furosemide, Tramadol

Here for eval of chest pain. Hx of Coronary artery disease, RCA stenting in 2004. In the past week, she has had an onset of chest pain that began with a few twinges of pain lasting for a few seconds, underlying the left side. In the past few days this has increased to to involve sternal area as well. The pain does not feel like a pulling muscle. She took some Devocet with improvement of symptoms.

She denies cough and dyspnea. There is no dysphagia or odynophagia. The pains are worse when lying on left side. No leg swelling. No calf pain or hemopytosis. She denies fever, chills, and PND.

Current Meds: Cozaar, Plavix, and Darvocet

Family Hx: Son and brother with MI; Mother with HTN.

Social: She is a non-smoker.

Phys Exam:
General -- overweight, pleasant in no distress
Neck: JVP not elevated
Lungs: Clear to asculation and percussion. Respirations are unlabored. No chest wall tenderness.
Cardiac: Rhythm is reg with normal S1 and S2 and 1/6 mid-systolic murmur at lower left sternal border. No radiation. JVP not elevated.
Abd: soft and nontender. No mass. No aortic bruit.
Extrem: Without edema. No calf tenderness.
Chest: X-ray reviewed personally by shows normal heart size and clear lung fields. No change from 2005. EKG shows show normal sinus rhythm. rate 56, with no repolarization change. Toponin I is .03.

IMPRESSION: Chest Pain. Suspect noncardiac pain, prob chest wall. Advised continued use of Darvocet. She was instructed in nitroglycerin use as trial. PHone follow in 48 hours. Possible Myoview test in future.

My thoughts and questions: Can we code a EKG, for example, 93010? How about an Xray code? We have a partial EKG strip that has the doctor handwriting stating, "Normal EKG" and the doctor also signs the EKG strip machine strip and his interpretation. I feel that this is not enough to code a 93010 because we don't have the doc saying, "Interpreted by me" or anything like it. Bottomline: I would lean towards just a 99203 with 786.50.
 

mitchellde

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So your office did not perform the EKG nor did the physician do the "interpretation" of the EKG. This is how I am reading this, is this correct? If so then no you may not code for the interpretation he is going off of what the interpretation shows. For Chest x rays in order to bill ofor the interpretation there must be a separately documented radiology interpretation report. If your patient brings the films/cd with them and your physician is providing his view as an overread then this cannot be billed with a cpt code as it is part of the E&M and is included in the MDM, and same goes for the EKG.
 

fredcpc

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EKG 93010 documentation

I am a remote coder, so I am not sure if the Internal Med office did it. I am trying interpret the notes that I have to the fullest degree possible. I do have:

1) EKG shows show normal sinus rhythm. rate 56, with no repolarization change. Toponin I is .03.
2) A partial EKG rhythm strip with the doctor's handwriting "Normal EKG" and then signing it.

So this is not enough for a 93010 or any EKG code? How would you code this encounter? If not, don't many Internal Med offices consider this to be enough documentation. Or, what am I missing?

BTw, The office originally coded a 93000. I doubt that is right. :confused:
 

Cyndi113

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If the MD reads the EKG and mentions it in his/her note and signs it, its 93010. How can you prove that the MD did not read it? As a coder, I'm not in the exam room.

I also have an MD that reads EKGs for the hospital. He confirms what is on the strip and signs them electronically. Again, I'm not there in the room when he is reading them. I bill 93010 for all that have a dx and are signed.
 

mitchellde

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I am a remote coder, so I am not sure if the Internal Med office did it. I am trying interpret the notes that I have to the fullest degree possible. I do have:

1) EKG shows show normal sinus rhythm. rate 56, with no repolarization change. Toponin I is .03.
2) A partial EKG rhythm strip with the doctor's handwriting "Normal EKG" and then signing it.

So this is not enough for a 93010 or any EKG code? How would you code this encounter? If not, don't many Internal Med offices consider this to be enough documentation. Or, what am I missing?

BTw, The office originally coded a 93000. I doubt that is right. :confused:
If the office performed the EKG in the office and the physician signs the rythym strip and makes a statement in the progress note of the EKG findings then it is a 93000.
If the EKG were performed elsewhere and your physician is the only one interpreting the strip then you may bill the 93010.
So if you have the actual rythm strip and it is a 12 lead and not a 3 lead, and it is your Doctor signing the strip then they did it in the office then he has the note in the chart on the findings so it should be coded as a 93000
If you did not have the actual strip with the doctors signature then with no better documentation we would have to assume the EKG was performed elsewhere and that he was documenting the findings of another doctor so we could not bill for it.
 

fredcpc

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EKG 93010 documentation

Debra -- I gained a lot from your last sentence....If you did not have the actual strip with the doctors signature then with no better documentation we would have to assume the EKG was performed elsewhere and that he was documenting the findings of another doctor so we could not bill for it. ;)

But I have a copy of a partial strip. The strip says, "Medical Complex, Internal Medicine". 1) But...I don't know if it is 12 or 3 lead...2) and does the doctor need to use the words "Interpreted by?" :D

The doctor signed, but of course I can't read the hand writing. But it is likely the doctor's writing. I am leaning toward a 93000, but I wish that I answer the those two questions.

Thank you all for the great input. Great learning here. And Merry Christmas and Happy New Year. Today is Christmas Eve.
 

fredcpc

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EKG 93010 or 93000 or just EM code

1) EKG shows show normal sinus rhythm. rate 56, with no repolarization change. Toponin I is .03.
2) A partial EKG rhythm strip with the doctor's handwriting "Normal EKG" and then signing it.

So this is not enough for a 93010 or any EKG code? How would you code this encounter? If not, don't many Internal Med offices consider this to be enough documentation. Or, what am I missing?

BTw, The office originally coded a 93000. If this was done in the Internal Medicine office, is it enough for a 93000 code? Or, do I need a complete EKG strip to code a 93000?

Happy Holidays!!:cool:
 
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