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Documentation of EKGs

  1. Default Documentation of EKGs
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    Billing for EKG:

    Does the provider need to document in their office note that this was done? What if they have documents to back it up, but didn't put it in their notes (does this count)?

    Is it required for us to select a different diagnosis for the ekg from the e/m or can we use the same dx code? What if there is only one diagnosis?

  2. #2
    If you're going to bill for it, I would say yes you need to document it. Also make sure you pay attention to the place of service, because there are 3 EKG codes, one for a global service, one for professional, and one for technical and you dont use -26/-TC. Remember if it's not documented, it didnt happen. I would make sure that any documentation you do get includes the tracing, as well as some form of written report detailing the findings, as that supports the physician component. As far as the diagnosis, I'm not sure about that, anybody else have any thoughts? Hope I was able to help a little!

  3. Default
    Yes, very helpful! Thank you! But do you know if you have to select a different diagnosis for the Ekg from the E/M?

  4. #4
    that I am not sure about. I think if the visit led to the EKG (i.e., they found something that made them want to do it) then you could use the same dx, but otherwise probably not. I personally dont have a lot of experience with using dx codes, as I work for a third party vendor that does bill review for auto insurance companies, and our Code Review dept only really looks at the CPT/HCPCS codes. I would definitely reach out to someone else on the dx code thing, maybe someone in your chapter that's more experienced? sorry I couldnt really help

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