Wiki Consult for Surgical Clearance

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fredcpc

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Hillsboro, OR
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How would you code this?

A patient, no history of heart issues, was referred to our cardiologist for a surg clearance at the request of the surgeon. Exp History, Exam and MDM was SF. A routine EKG was performed and interpreted. Results were sent back the surgeon.

I think this is consult, probably a 99241. EKG 93000, but what are my dx codes for both CPTs? :confused:
 
You could you the pre-operative codes V72.8x, it would depend on the documentations of your doctor. Did the doctor interpreted the EGK and give a diagnosis? I hope this helps.
 
The provider did interpret the EKG, but the patient has no heart problems. So we are left with very general documentation. We are unclear of what the surgery is even for. I agree with the
V72.8x, but I was just wondering if I am missing something here.

:confused:
 
Not covered

Reviewing the LCD for Preoperative Services (National Govt Services) this EKG would not be covered as it would be considered "part of a pre-operative examination, where there is an absence of signs or symptoms indicating a need for the test, is not covered under the Medicare benefit. Such studies will be considered not reasonable and medically necessary."

Best to check with your MAC or payer before going crazy looking for a dx code to make sure the EKG will be separately covered.
 
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