EKG's...More Than Just Amusing
Our billing department does not have access to the MUSE application. A statement such as "Please see MUSE for complete EKG interpretation" doesn't always get billed. Reasons are multi-factorial.
For EKG billing, you must document 3 of 6 of the following elements:
1. Rhythm or rate
5. Notation of comparison to prior EKG
6. Summary of clinical condition
I recommend making it easy on the coders. Try not to bury the EKG interpretation in a long paragraph. Use the EKG click box or separate it in your dictation.
You can bill for more than 1 EKG. Clearly document each EKG interpretation. From a medical legal viewpoint, it's always in your benefit to time your EKG reads.
For Past Medical/Surgical, Social, Family History:
"Negative," "noncontributory," "not significant," "unknown," or "reviewed in chart" are not considered sufficient to support these history components.
** For "unknown" you must clearly indicate a high acuity caveat or document if the patient is adopted.
*** Our coders do not reference nursing notes for "reviewed in chart." These must be imported into your power note for the coder to see it.
**** It is ok to say "No past medical history"
Disclaimer: Information contained in this blog is the opinion of the author and does not necessarily reflect the official opinion of Carolinas HealthCare System. Application of material contained in this blog is at the discretion of the practitioner to verify for accuracy.