Wiki Help please- Proper documentation for Stress Echo with 93325 and 93320

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Dinaerwin

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I code for a Cardiology practice that frequently performs Stress Echo's in the clinic. I bill 93351, but I am having trouble finding guidelines on billing 93325 and 93320. Their reports do not specifically state that Doppler or Color flow was used. I know it is best practice for the providers to state that specifically in the report, but I am wanting to make sure I have the proper guidelines before approaching them with this. Can anyone help me to know if I can tell from the report that 93325 and/or 93320 were done without the provider stating that?
 
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The short answer is the Coding Golden Rule. If it's not documented, it wasn't done.

AAPC says this, in part, here (click me): A color flow study is a visual assessment of blood flowing through the heart. Unlike 2-D and Doppler studies, the color flow study does not produce numeric measurements. While the ICAEL standard references that “any regurgitation, shown in at least two imaging planes with color Doppler” should be documented, there are no reliable guidelines as to definitive documentation in the report to support the performance and interpretation of the color flow study. It is best to specifically document when a color flow study is performed and provides a brief summary of what is revealed: normal or abnormal.
 
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