Cardiology Coding Alert

"Getting paid for electrocardiogram (ECG) interpretations can be challenging. Cardiologists should make sure they are using covered diagnosis codes and make separate billing arrangements with hospitals for the interpretations they perform to maximize reimbursement for the services provided, coding experts say.

Cardiologists often interpret the ECG of a patient whose diagnosis was made by another physician. The patient may have been sent to the cardiologists office by a primary-care physician (PCP), or admitted to the hospital by the PCP, an emergency room physician or a surgeon.

An ECG may be performed in the office using equipment owned by the cardiologist or his or her practice (93000, electrocardiogram, routine ECG with at least 12 leads; with interpretation and report); or the cardiologist may do an interpretation (93010, interpretation and report only) at the hospital. Either way, another physician may have diagnosed the patient, and when the bill for the ECG interpretation is submitted by the cardiologist, it will be denied if the diagnosis code isnt covered by the carrier, says Terry Fletcher, BS, CPC, CCS-P, a cardiology coding consultant in Dana Point, Calif.

Similarly, when a patient is referred to the cardiologist for a pre-operative clearance ECG, the subsequent claim often is denied. Pre-operative clearance is standard procedure at many hospitals, but without an approved diag-nosis, the cardiologists claim will be rejected, Fletcher says.

Although interpretations are not reimbursed at a high rate93010 has 0.35 relative value units (RVU), paying out at a national average of $12.60ECGs are among the top 50 services provided by cardiologists. That means those $7-$15 fees add up, and now Medicare carriers are scrutinizing ECG interpretations closely to control costs, says Cynthia Swanson, RN, CCS-P, a coding and reimbursement specialist with Seim, Johnson, Sestak & Quist, LLP, in Omaha, Neb.

Medicare doesnt always want to pay for ECGs done in conjunction with a cataract or orthopedic procedure. The doctors may believe the test is medically necessary, but Medicare wont pay for it, Swanson says. Now, Medicare does not cover tests when diagnosis criteria arent met or when the test is preventive (e.g., screening) and is deemed not medically necessary by the Health Care Financing Administrations (HCFA) definition.

7 Tips to Improve Pay Up

The following helpful guidelines can help you optimize reimbursement, minimize denials and stay in compliance while coding with the information you have.

1. Check Incoming Diagnosis From Referring Doctor. The information in the order form from the primary-care physician requesting the ECG may be incomplete. For example, if the patient is about to have an operation to remove cataracts, the form may not even say cataract. Instead, all it says is patient scheduled for surgery. And the cardiologists may not have the luxury of waiting until the right diagnosis arrives.

Consequently, cardiologists and the doctors who send them ECG patients must communicate better, although it may be difficult for a hospital to cooperate in getting the physician accurate, appropriate information about diagnoses.

Swanson suggests the cardiologist provide the referring physician with a simple form that, when completed, will explain why the ECG is being ordered. Gestures like that let them know you are trying to make it easier for them, she says.

2. Find Out Which ICD-9 Codes Your Carrier Covers. Indications for ECG Medicare coverage are based on the diagnosis provided on the HCFA 1500 claim form, Swanson says, and local Medicare carriers publish lists of approved diagnosis codes that must be used when filing claims for ECGs or ECG interpretations. (See box on p. 4.)

A few V-codes are among the listed ICD-9 codes Medicare allows. Swanson suggests that signs or symptoms or regular diagnosis codes be listed ahead of V-codes, which should be viewed more as confirmatory diagnoses.

Note: Although HCFA sets broad Medicare guidelines, Medicare carriers in different states may differ somewhat concerning which diagnoses they allow. Check with your carrier to determine which ICD-9 codes they consider acceptable.

3. Make Sure the Documentation Supports the Diagnosis. The medical record documentation must support the reason for the test, Swanson says. It should include patient history and signs and symptoms to substantiate the medical necessity of the ECG, she says, noting that testing that appears to have been done for routine screening will be denied.

Coders and billers must be cautious when using lists of payable diagnoses. Using covered diagnosis codes in an effort to get claims paid when the medical record documentation does not support the listed claim diagnosis can lead to a potential false claim situation, Swanson says. She further notes that lists posted in the office with headings such as good pay diagnosesuse for claims filing can be misleading to those reviewers from the outside or a Medicare auditor. The bottom line is: You need to make sure the diagnosis information in the
medical record corresponds with the service billed.

If a claim is denied for medical necessity, review the documentation and determine the medical need for the test. On appeal, additional information can be submitted, Swanson says.

4. Dont Modify ECG Procedure Codes. ECG codes dont take or need modifiers. There is no reason to use modifier -26 (professional component), for example, on an interpretation because 93010 clearly states it is for interpretation and supervision only.

5. Medicare Wont Pay for Screenings. Because Medicare doesnt pay for screenings, baseline ECGs may be denied. If there is a problem, the subsequent ECG will be paid. Some private carriers, in particular, HMOs and other managed care groups, now cover screenings, so check with your payer. All carriers have medical policies that spell out which codes and situations will be covered.

6. Get a Waiver From Your Patient. If the carrier wont pay for the screening, the fee may be collected from the patient as long as he or she is aware of that possibility before the procedure is performed. Regardless of the payer, you may want your patients to sign a waiver indicating that if the referred diagnosis is deemed not medically necessary, the patient will be responsible for payment.

Note: Many cardiologists forego this step and absorb the cost to maintain good relations with their patients.

7. Make a Deal With the Hospital. Hospitals may require routine ECGs before procedures even if the diagnosis code is not on Medicare's list. For example,
V-codes such as V72.81 (preoperative cardiovascular examination) are not on the list. Therefore, even though the hospital may get reimbursed if the ECG is part of a larger diagnostic related group (DRG), the physician does not get paid for the interpretation.

The hospital and doctors may argue that the ECG is medically necessary for the surgery, but Medicare considers it a screening and wont pay for it. Because situations like these are common and because the hospital has quality assurance requirements, cardiologists should try to negotiate separate, flat-fee contracts for ECGs from the hospital.

We have a contract with our hospital that basically says we get paid for the ECG regardless of whether they get paid or not, says Debbie Rhodes, the director of reimbursement in the 31-physician practice of Atlanta Cardiology Group.

Rhodes warns, however, that hospitals have terminated contracts because in some situations, they, too, couldnt get paid by Medicare when the ECG-referring physicians failed to provide an approved diagnosis."