Question: Virginia Subscriber Answer: priate and possibly fraudulent coding. CMS describes its guidelines for this issue in Transmittal AB-01-144 (Sept. 26, 2001) in which the agency states that a physician must confirm a diagnosis based on the test results. This CMS transmittal goes on to say that if the test results are normal or nondiagnostic, you should code the signs or symptoms that prompted the test -- in other words, the indications. (See www.cms.hhs.gov/transmittals/Downloads/AB01144.pdf��'to read the transmittal.)
Similarly, the ICD-9 coding guidelines for diagnostic testing instruct you not to "interpret" what a study says, but rather to rely on the physician's stated diagnosis. If the ECG findings seem like an important component of the case -- and may play a role in substantiating the medical necessity for the visit��'-- you should query the physician regarding the diagnosis.
Code the technical component only as 93005 (... tracing only, without interpretation and report). If the physician provided only the professional component, use 93010 (... interpretation and report only).