Maria Posted Fri 24th of September, 2010 17:41:51 PM
We use a template system for our EDs. All of the templates with EKG or XRAY areas contain check boxes that say “interp by me” , “reviewed by me” or “discussed with radiologist”. If the physician provides documentation in these areas but fails to check one of the boxes, could it be a billable service based on the amount of documentation? Must the physician specifically indicate that he personally did the interpretation? Thank you in advance for any advice!
SuperCoder Answered Mon 27th of September, 2010 13:30:28 PM
To Bill separately other than ED service: The “Interpreted by me” MUST be Checked.
But only Checking of box is not enough, we need Documentation in detail that can support that the physician has interpreted these services.
For example, in case of EKG the EKG scan must be attached with the document should show the Ordering as well as the Interpreting physician’s name.
If the Box for EKG “Interpreted by me” is checked, but there is no documentation to support that the physician has interpreted the report, it is always better to “flag” such report and send back such report to ED physician for “Clarification” requesting confirmation and also to attach the Scan document in support if he has interpreted. Even if the ED physician may not be able to furnish such document, but if he confirms that he has interpreted the EKG, then the coder can bill EKG separately.
If none of the box is checked, but there is a documentation and also attachment of Scan, but no where it is saying that the ED physician has interpreted it. It is highly probable in such cases that the ED physician might have interpreted it, but we can’t assume such cases. So, in such a case we should “flag” the report as “Clarification” for confirming from the ED physician.
In case the physician doesn’t confirm in any of the above cases, then we can’t bill such services.
The bottom line is “the documentation should be complete.”
Firstly, whether the ED physician has documented it properly?
Secondly, if the Coder has taken enough care to confirm in case of lack of documentation?