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Wiki Hi! I have a question about when to separately report a test during E/M

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Hunter16

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Hello fellow coders,

I am currently a CPC-A and working on Practicode. When billing an E/M code along with EKG report, I get confused sometimes when reading through the clinical record. I don't always know when I should separately report say, code 93010 for an EKG, just as an example. I am wondering what keys words will help me decide when to separately report this. For example, in the record, if the doctor writes: "Results [of the test] were independently viewed by me and interpreted by the radiologist and contemporaneously by me." Is it the use of the word "independently" or "contemporaneously" or something else I should be looking at that hints at a test being separately reportable?

Thank you for any assistance!

Ryan
 
Whoever did the formal, and separate, interpretation and report of the test is who bills for it. In your example, "Results [of the test] were independently viewed by me and interpreted by the radiologist and contemporaneously by me.", the radiologist did the interpretation and report. The provider simply took a look at it, so there was no formal interpretation and no separate report from that interpretation. If there are tests performed, the interpretation and results should be separately documented.
 
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