Cardiology Coding Alert

Although performing wall motion and ejection fraction services won’t change your physician’s reimbursement, that doesn’t mean she shouldn’t document the services. “Best practice is to routinely document all services provided,” says Cynthia A. Swanson, RN, CPC, CEMC, CHC, senior manager, healthcare consulting, at Seim Johnson in Omaha, Neb. “The new 2010 codes (CPT 78452 and 78454) include a detailed definition of each service as it relates to myocardial perfusion imaging services. By documenting the various components of testing performed, the medical record will accurately support the service(s) provided to coincide with the CPT code selected.”

Reasons for needing thorough documentation include "the medical record serving as a legal document, information regarding the patient’s care, evidence of service(s) provided in defense of insurance fraud or malpractice, support for levels of care and support for services performed to payers,” Swanson says.