Wiki Help Needed! Coding off EKG & X-Rays

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GSCoder07

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I have read where coders aren't allowed to code off the EKG or x-ray report and we can only code the diagnosis after it's been read by the treating physician.

Example: Dr. A, who is a Cardiologist, reads an EKG in the ER. He states in his report, the patient has an AV paced rhythm with a prolonged AV conduction. Dr. B, who is an ER physician, reads the EKG and notes that the patient has a left bundle branch block.
Do I code from Dr. A's notes or Dr. B's? Does anyone have any links or information pertaining to this subject?

Thank you so much in advance for your help!
 
It depends on who you are coding or billing for. If you are billing for the reading cardiologist, then use his interpretation. If you are billing for the ER physician and he does his own interpretation, use his diagnosis.
C Collison CPC, CCC,
 
Thanks for your reply C.Collison.

It's pro-fee coding. Since that is the case, would we bill off the EKG/x-ray and not the physician notes?
 
I am assuming you are billing to the ER physician, in this case, Dr. B. We would need to go with the clinical impression for EKG - left bundle branch block. Most coding rules would not allow us to code from the reports and only allows from the physician notes.

If we are allowed to code from x-rays, that could be for the laterality or more specificity only.

Thanks,
Anitha
 
Thank you for replying back Anitha.

I am coding for the cardiologist. For his charges, we bill 93010-26 when the EKG is performed either in the ER or as an inpatient. Since I am billing for the cardiologist, I can bill from the EKG, correct?

I've seen a bit of conflicting information so I just and to be sure I'm billing it correctly.
 
Then, you should be going with the cardiologist interpretation, since he went as a consultant and shared his findings after EKG.

Hope this helps.


Thanks,
Anitha
 
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