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Wiki sources of documentation for dx coding

Rita Bartholomew

Rita Bartholomew

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Greater Portland (Maine)
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I have a question specifically about CPT 93010 -- coding for the interpretation and report of an EKG. Our coder is currently using only the diagnosis provided by our cardiologist on the EKG printout itself. The cardiologist is an employee of our hospital and we use an electronic health record. Can our coder access all the records from our ordering provider(s) to obtain any history or signs/symptoms which prompted the EKG order?

The essence of what I'm asking is: is the coder limited to only what's on the EKG graph/report for assigning diagnoses to the claim? Can't she use the ordering doctor's record as well?
 
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