Independent Visualization of Images & Tracings
The documentation guidelines that dictate what needs to be in a note to support each level of service break visit notes into three key-components: History, Exam, & Complexity. The complexity component consists of three obscure calculations called Data, Risk, & Presenting Problems. The calculation called "data" assigns points to different types of data. To support a 99214, this calculation must yield a total of 3 credits. The highest levels of service require a total of 3 credits.
1 credit is generated for ordering an EKG or reviewing an EKG report, 2 credits are awarded for independently visualizing an ECG tracing. When a doctor orders an EKG and independently visualizes the tracing, 3 credits are awarded. This can be inferred from the official documentation guidelines and it was confirmed in the October, 2004 CMS correspondence presented below.
One of the Medicare Administrative Contractors, Noridian, published an article in 2009 that contradicted this otherwise universal standard. I opened a dialogue with Noridian regarding their publication and they published another article reversing their position in 2015. The guidance Medicare provided is presented below along with the 2009 & 2015 Novitas publications.
It is ideal to clearly document independent visualization of the tracing with verbiage that can't be misinterpreted as anything else. Ideally, your note would say, "the EKG was independently visualized and found to reveal..." Just saying, "the EKG reveals..." may not be sufficient.
This post only addresses EKG tracings. However, the concept of "independent visualization" applies to any images or tracings. As such. make sure to give yourself credit for independently visualizing x-rays, echos, nukes, angiograms, and other images/tracings.
Promotional Message: If Medicare demands a penalty for over coding, call me - I might be able to help.