tci ED Coding & Reimbursement Alert - 2006 Issue 2

READER QUESTIONS: Leave Dx to Physician With EKG

Question: If the physician hasn't indicated the EKG results in his final diagnosis, should we still code the findings? He wrote a complete interpretation on the strip. He says yes, because usually he has another diagnosis to justify the EKG.Massachusetts Subscriber Answer: For you to report findings from the electrocardiogram, the physician must document the findings as a final diagnosis. Choosing a diagnosis yourself based on the patient's test results--even when that diagnosis seems obvious--is inappropriate (and possibly fraudulent) coding.CMS describes its guidelines for this issue in Transmittal AB-01-144 (Sept. 26, 2001), in which the agency states...

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