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ED Coding and Reimbursement Alert

You Be the Coder:

Include EKG in Chart Notes

Published on Mon Mar 28, 2005

Question: Our physicians want to bill for CPT code 93042. Can the "report" be documented on the ED record? How detailed must it be? For example, does "Rhythm/Monitor: NSR" documented in the physician notes meet all requirements for the code?

Pennsylvania Subscriber

Answer: The typical documentation in the emergency department record for 93042 (Rhythm ECG, one to three leads; interpretation and report only) includes rate and rhythm. For example, "HR 90 NSR" would be acceptable.
 
Keep in mind that you should have distinct medical necessity for the monitor reading -particularly if an electrocardiogram is also being performed. There is no requirement that an interpretive report be on a separate piece of paper, and the physician can record it in the chart along with her other notes.
 
Medicare requires that the documentation of an interpretive report be a complete written report - similar to that usually prepared by a specialist - and that the report should address the findings, relevant clinical issues, and comparative data when available.
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