DOCUMENTATION TIP

DOCUMENTATION TIP: EKG INTERPRETATIONS

Documentation Tips: EKG Interpretations

Document the interpretation of each tracing (some patients have more than one) in a separate paragraph. Do not just bury the EKG interpretation in the MDM or ED course discussion.

Leave no doubt as to who performed the interpretation

  • “Per my interpretation”
  • “As interpreted by me”

The interpretation must include appropriate comments on any 3 of the following 6 elements:

  1. Rate and/or Rhythm;
  2. Axis;
  3. Intervals;
  4. Segments;
  5. Comparison with a prior EKG if one was available to the ED provider; and
  6. Summary of clinical condition

Per Medicare CAC: “An EKG with interpretation must have the full graphic tracings with formal written or printed interpretation on file for review. The interpretation should appear on the designated sections of a page formatted EKG or written in the clinical records. Interpretations should include appropriate comments on rhythm, axis intervals, acute or chronic changes and a comparison with the most recent tracing. While every single parameter is not required for each tracing, the appropriate measurements must be mentioned if the purpose of repeated EKGs is to monitor the effects of a given parameter, e.g., the QT interval.

Examples of billable EKG interpretations:

  • ‘Per my interpretation, EKG reveals normal sinus rhythm, no axis deviation, no acute changes.’
  • ’12-lead EKG reveals atrial fibrillation, rapid ventricular response, non-specific ST-T wave changes as interpreted by me.’
  • ‘Per my interp., EKG reveals normal sinus rhythm, normal axis, T-wave inversion in V3 and V4 and T-wave flattening and high laterally. No EKG was available for comparison.’
  • ‘EKG reveals normal sinus rhythm with rate of 66, PR and QRS intervals within normal limits, some QRS complexes in lead III and T-wave abnormalities in I and aVL, but when compared to prior EKG there is no acute change noted. EKG interpreted by me.’

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