# Documentation Guidelines



## asnelling (Jun 3, 2010)

I need some help please.  I am looking for documentation guidelines for several CPT codes.  We are trying to make sure that we have everything we need in the documentation for our procedures i.e description of procedure, findings.  Does anyonw know where I can look for this type of information?  For instance: CPT 93293 we receive a report from the company that has the DX and findings.  Is this acceptable or do we need a seperate report from the physician?    I am trying to find something in writing.  Any suggestions?

Thanks!


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## sbicknell (Jun 3, 2010)

93293  Transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with physician analysis, review and report(s), up to 90 days 

A physician interp is required to code/bill this code. Your physician can use the data recieved by external company but he must provide his own interp.  He can make notes on the external report and sign and date. He can (should) also document his interp in his encounter note.

It's kind of like the EKG tracing and physician interp.  He can do a separate report or he can note his interp on the tracing and sign and date

And an interp is not just a sign off on the data or a sign off on the "machine interp". The physician's interp must be his interp

For your documentation in general, see if this link (and the imbedded links) help

http://www.trailblazerhealth.com/CERT/DocumentationTips/default.aspx?DomainID=1


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## asnelling (Jun 4, 2010)

Thank you for your help.  I really appreciate it.  I will check out the link.  

Amie


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