EKG reports

I need some help in determining what Medicare considers a report for codes 93000 or 93010. I did look through the archives on this site but did not find anything that addressed the EKG report.

Here is my question:
Place of service is a physician office. If a patient comes in with a problem and the physician does an EKG in his office is the fact that he signs or initials the tracing enough to validate and code as a report or must he make a notation about the EKG. Exactly what would Medicare require as far as documentation to code interpretation and report. Also, if my physician owns the equipment in his office I can bill the 93000 is that correct?

Ekg

Initialing a report is not an interpretation. The physician must document on results in a separate note (similar to what a radiologist would do). If the physician bills as place of service 11, he may bill global code.

EKG Reports

The tracings are the test results.

The physician needs to interpret those results in order to bill for the interpretation and report. The MD should write "Normal EKG, sinus...." or "afib with XYZ" as their interpretation of the report.

Required Documentation

I'd like to know what the CMS required documentation is for EKG code 93010 in the professional inpatient side.

Ekg

An interpretation and report is different than a review. CPT does not clearly state a documentation standard.

Medicare states that the report must be a complete written report similar to that usually prepared by a specialist in the field and should be consistent with the service furnished. Medicare policy also states an "interpretation and report" should address the findings, relevant clinical issues, and comparative data when available. "ECG normal" is deemed an insufficient interpretation and report. Individual carriers may develop their own standards.

Medicare does not require that the ECG interpretation be recorded on a separate piece of paper, rather a complete written interpretation can be recorded within the patient treatment records. However some Medicare carriers have independently established more restrictive criteria.