Internal Medicine Coding Alert

Question: A patient presents with complaints of periodic fainting spells and perception of heart palpitations. The internist performs an ECG with normal findings. The physician orders follow-up testing for a later date. How should I report this?

Tennessee Subscriber

Answer: Assuming the internist performed a routine electrocardiogram (ECG), you should choose between 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) and 93010 (... interpretation and report only), depending on which elements you're reporting.

Because the internist did not document a definitive diagnosis, you should report the diagnosis for this visit based on the presenting signs and symptoms: awareness of  alpitations (785.1, Palpitations) and fainting (780.2, Syncope and collapse). These ICD-9 codes should indicate medical necessity for the ECG.