Ask Dr. Z

I have a physician who did a biventricular ICD implantation, and at the end of the report just states, "Please see Implant Device Record for Implanted Hardware and Thresholds." There is nothing in the cardiology report that gives any information about the details of testing the device with a shock or any threshold information, BUT all of the threshold information can be found on the "implant record" - a separate form that has the parameters, stimulation threshold, device measured info, and pacing threshold, but that form is not signed by the cardiologist (it is scanned into the medical record). Can we still bill code 93641 with this unsigned form and the cardiologist just referring to it in the final signed ICD implantation report? Also, what is the difference with 93641 and 93642? We are not sure what documentation is necessary for either code.