Stress or Rest

daniel

True Blue
Messages
537
Best answers
0
Which code set would you use for this note.


CPT 93306
or

CPT 93351,93320,93325





PROCEDURE:
The patient underwent 2-D, M-mode and Doppler echocardiography including continuous wave, pulsed wave and color-flow Doppler imaging.

NORMAL (ADULT) M-MODE VALUE NORMAL RANGE
LVID at end-diastole: 5.2 cm (3.5-5.6 cm)
LVID at end-diastole (m2): 2.8 cm/m2 (1.9-3.2 cm/m2)
LVID at end-systole: 3.4 cm
SEPTAL THICKNESS: 0.7 cm (0.07-1.1 cm)
POSTERIOR WALL THICKNESS: 0.8 cm (0.07-1.1 cm)
AORTIC ROOT: 3.2 cm (2.0-3.7 cm)
AORTIC ROOT (m2): 1.7 cm/m2 (1.3 to 2.2 cm/m2)
LEFT ATRIAL SIZE: 3.8 cm (1.9-4.0 cm)
LEFT ATRIAL SIZE (m2): 2.1 cm/m2 (1.2-2.1 cm/m2)
EJECTION FRACTION: 65 %
INTRACARDIAC THROMBUS: Not Present
PFO/ASD/VSD: No

DOPPLER MEASUREMENTS:
AORTIC VALVE PEAK: 12.1 mmHg, MEAN: 1.16 mmHg
PULMONIC VALVE: 2.7 mmHg.
Impression/Conclusions
CSU-020210-17.








Thank You
Daniel, CPC


I'm asking because the physician billed code set CPT 93351,93320,93325. I think this documentation doesn't support these codes because there's no mention of the stress portion being done.
 

ciphermed

Guru
Messages
187
Best answers
0
The documentation appears to lack documentation significant for...

"rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress"

No indication as to whether or not the patient was stressed via Bruce protocol or via pharmacology (Adenosine, Dobutamine etc.)

Perhaps that the EKG stress portion is documented in a separate report?

Currently looks more like 93306.

Hope this helps,
 
Top