Ask Dr. Z

I would appreciate your guidance on documentation. It has been proposed that the CPT guidelines before a section are technical requirements that need to be performed, but are not necessary to be documented in the professional report unless they are “clinically relevant”. For instance, for a complete echocardiogram (93306), the guidelines state the structures that need to be evaluated or the reason that they can’t be visualized needs to be stated. If, for instance, the right atrium was not referenced in the report because it was not deemed to be clinically relevant, could a complete echocardiogram be billed if all of the other elements were on the professional report? In your opinion, have we met the requirements for documenting a full echo (without including all the elements in the professional report) because we have the supporting tape to show that the service was rendered completely? Secondly, would a statement indicating that “the structures were visualized” suffice? In other words, must it be an interpretation of what is seen?