Dear NES Providers,
My name is Dr. David Yin and I am the Director of Medical Education and Documentation Integrity for NES. First of all, I just wanted to say it is an honor to be a part of NES and it is also an honor to help keep you all up to date on the ever-evolving entity known as Emergency Medicine and help improve our documentation as a group. I welcome your questions and am happy to discuss any issues or problems that you might have.
Starting this month, I will be sending out a quick monthly update/newsletter about clinical documentation pearls. Documentation in its entirety I understand is not the world’s most exciting topic (I can assure you that I enjoy it as much as you all do). However, documentation is vital to the growth of NES. It is necessary to discuss the what, why, and how of clinical care delivered to patients. It can also very much help you in case litigation is ever brought against you. Lack of thorough documentation can absolutely hurt you.
Documentation can be quite a convoluted conundrum for many. It is my job to help you all wade through these muddy waters and make sense of it. Thus, my monthly update will be called “Lost in TranslatYin.” Because just like the movie, things may seem overall disconnected and chaotic but there are sometimes moments of clarity that allows you see the big picture.
The first documentation pearl is about documentation of EKGs. Documentation of EKGs is monumentally important. An EKG is billed at CPT code 93010 and equals 0.24 RVUs. 0.24 RVUs is a significant amount. In order to document an EKG correctly, we need to include at least 3 of the following categories 1) Rate 2) Rhythm 3) Axis 4) Interval length 5) Q waves 6) ST changes 7) T waves 8) Heart blocks 9) Comparison to prior EKGs. I know this sounds like a lot but let me give you a few examples:
- EKG shows NSR with HR 80, normal axis, normal intervals, no ST changes
- EKG shows afib RVR with HR 130, right axis, Q waves inferiorly, unchanged from prior EKG
- EKG shows NSR with HR 62, RBBB, left axis, prolonged QTc at 480
- EKG shows wide complex tachycardia with HR 160, normal axis, prolonged Qrs, no heart blocks
- EKG shows narrow complex tachycardia with HR 180, left axis, normal intervals, new from prior EKG
All of these examples are acceptable. I frequently use example A in my documentation. It’s short, sweet, and to the point.
Please let me know if any of you have any questions. Hope you all have a great week.
Humbly yours,
David Yin, MD
