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Diagnosis Coding for 93016

Date: Mar 15, 2021

Question:

Our stress tests are supervised by APPs, and they bill 93016. Currently, we are using the 'reason for exam' as the diagnosis for the supervision and the appropriate diagnosis (based on the documented interpretation) for the 93018 billed by the MD.

Recently an auditor told me that IF the stress test interpretation is available in the chart when we are coding the supervision 93016, we should be assigning the appropriate diagnosis from the interpretation to the supervision.

This doesn't seem correct to me -- if we are coding/billing for the supervision only, we do not know the final diagnosis at that point in time. If the test is stopped for any reason, we DO use that diagnosis code (i.e., tachycardia or chest pain).

Do you recommend coding a diagnosis from the INTERPRETED stress test as the diagnosis for the SUPERVISION of the stress test?

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