Primary Care Coding Alert

Question: Our doctors are under the impression that since our electrocardiogram (EKG) machine generates a computerized interpretation, they don't need to write a separate note for the interpretation that they are reading and charging. They think they just need to state that they agree with the computerized report, and then sign it. We are uncomfortable with that situation. What is the protocol here?

South Dakota Subscriber

Answer: You should follow CPT guidelines closely. CPT requires a separately identifiable, signed written report, so if your payer adheres strictly to CPT guidelines for EKG interpretation, it will probably deny claims with only a physician agreement and signature.

CMS also requires that the interpretation be comparable to one prepared by a specialist in the field, or meet the standard in that facility, so even if your physicians decide to start creating separate reports, you'll want to keep those standards in mind.

But CMS' requirement for interpretations cuts both ways: If the specialists typically sign the computer-generated interpretation with a notation that they agree with those findings, then the family physicians doing the same should not be problematic. You should contact the payer involved, because the acceptability of this practice may depend on who's reimbursing you for the service.