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

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
 
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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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