Primary Care Coding Alert

Question: What should my family physician document to claim electrocardiogram (ECG) interpretation and report (I&R)?

Wisconsin Subscriber

Answer: He should write why he agrees or disagrees with the machine's description and sign and date the report. For instance, the FP might write, "Disagree with machine findings because my interpretation of the ECG supports that changes noted are a variation of normal and are unchanged from prior tracing."

When your FP's documentation substantiates that he performed more than just a simple review of the report, submit 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) or 93010 (... interpretation and report only), depending on where the service occurred.

If your physician performs the ECG in his office, use 93000 because he provides both the technical (tracing) and professional (interpretation and report) service components. Submit 93010 when he interprets a hospital-performed ECG because the hospital provides the technical component and the FP performs only the professional component.

If your FP performs the ECG in the office but asks another physician, such as a cardiologist, to interpret the report, use 93005 (... tracing only, without interpretation and report). The cardiology coder should submit 93010.