Question EKG - tracing and independent interpretation


New York, NY
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There see to be an invisible line between coding for a cpt and what qualifies for an independent interpretation.
the definition for independent interpretation of a test states - “The interpretation of a test for which there is a CPT code, and an interpretation or report is customary. This does not apply when the physician or other qualified health care professional who reports the E/M service is reporting or has previously reported the test." It further states "A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test"

In an outpatient setting, the provider orders the EKG. There is usually no word, phrase, statement nor sentence in the provider note of the outcome/finding of the EKG. Often, there is not even a documented review of the EKG. The ordering provider takes the credit for the service as either a cpt code or to drive up data as is best for the value of the total service.

Is this how it should be?

With the 1995 guidelines, coders were encouraged to consider an EKG tracing with a provider signature and the words "agreed" stamped on the tracing -as sufficient to code for the CPT 93010.
with the 2023 guidelines an EKG tracing with the provider signature and the words 'agreed" stamped on the tracing - is sufficient to be considered as an independent interpretation.
In order for a test to be credited as independent interpretation there needs to be an outline documented on the interpretation. Not a full-on report, but a summary of that providers OWN interpretation of what was reviewed. In addition, independently interpreting a diagnostic test alone does not necessarily mean that it will be credited as moderate complexity in column two. There needs to be a substantial reason that is medically appropriate for the provider to do his or her own individual interpretation. Also, you need to make sure the provider did not order that test, nor was it separately billable, nor was it ordered by another provider in the group practice. More often than not, I do not give credit for independent interpretation unless the documentation clearly identifies all the necessary requirements for me to find the support for independent interpretation.