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Thread: Documentation

  1. #1

    Default Documentation

    AAPC: Back to School
    My question is if a doctor does an EKG and does not document it in the notes but have the EKG strip in the medical records can you bill a 93000? Or is it as the old saying goes, if it was not documented it was not done. Thanks for your help

  2. #2
    Join Date
    Apr 2007
    Bangor, Maine


    Since that is a pretty pricey test, I would query the chart back to the physician before you final bill it. Maybe it was just an oversight on their part.

  3. #3
    Join Date
    Apr 2007
    Daytona Beach, FL


    Based on the code you want to use I would not bill.

    93000 is for the EKG, interpretation and the report together. If the doctor does not document the procedure, the results and create a report - you cannot bill this code. At the Urgent care where I code, the docs only do the interp and if it is not documented, we do not bill, even with the strip in the chart. The EKG test is done by the adjacent lab who bills for that portion but we get a copy of the strip so just the possesion of the strip does not warrant being able to bill for the EKG either.

    As Ltibbets suggests - check with the doc for documentation, otherwise it is not billable.
    Jodi Dibble, CPC

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