I’m trying to find documentation for what needs to be documented in the office visit when an EKG is done. Patient will see our provider and if he feels an EKG need to be done he will tell his MA. MA will hook the patient up and print the report. Report is than handed to provider provider to review. Patient at this time is still in the clinic. What is happening is provider is not mentioning in his document that EKG was done. So trying to find out if we can go back using the EKG reports and see what EKG’s where missed. But if they provider does not mention the reading or the results of the EKG can we code 93010. We are an RHC clinic so we can only charge 93010. We can not use 93000. Any help on this would be greatly appreciated. Also I have read that MDCR can only be charged once a year for the 93010 and has to be done a their MDCR Wellness Visit. Is this true also.