Internal Medicine Coding Alert

Question: If the physician hasn't indicated ECG results in his final diagnosis, should I code the findings? The internist wrote a complete interpretation on the strip. He says yes, because usually he has another diagnosis to justify the ECG.

Virginia Subscriber

Answer: For you to report findings from the electrocardiogram (ECG), the physician must document the findings as a final diagnosis. Choosing a diagnosis based on the patient's test results -- even when that diagnosis seems obvious ...quot; is inappropriate 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. If the test results are normal or nondiagnostic, you should code the signs or symptoms that prompted the test.
(Visit 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 internist regarding the diagnosis.

Choose the CPT ECG code based on how much of the ECG service the physician's office provided. If the physician's office provided the entire service (both technical and professional components), assign 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report).

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).

Answers to You Be the Coder and Reader Questions were reviewed by Kathy Pride, CPC, CCS-P, director of government program services for QuadraMed in Reston, Va.; and Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm.