tci ED Coding & Reimbursement Alert - 2005 Issue 4

You Be the Coder: Include EKG in Chart Notes

Question: Our physicians want to bill for CPT code 93042. Can the "report" be documented on the ED record? How detailed must it be? For example, does "Rhythm/Monitor: NSR" documented in the physician notes meet all requirements for the code?Pennsylvania SubscriberAnswer: The typical documentation in the emergency department record for 93042 (Rhythm ECG, one to three leads; interpretation and report only) includes rate and rhythm. For example, "HR 90 NSR" would be acceptable.  Keep in mind that you should have distinct medical necessity for the monitor reading -particularly if an electrocardiogram is also being performed. There is...

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