Cardiology Coding Alert

The trick is pinpointing diagnostic electrocardiography.

ECGs are bundled into cardiac catheterizations. But if you overlook opportunities to report ECGs on cardiac catheterization days, you could be shortchanging your practice. Apply the rules below to stay on the right side of the line between legitimate reimbursement and noncompliant coding.

Start With a Brief Look at ECGs

ECG is short for electrocardiography. The abbreviation EKG is also used. During this noninvasive procedure, a patient has electrodes placed on his skin, such as on the chest, arms, and legs, to produce an electrical recording of the heart. Technically speaking, the ECG is a graphic tracing of the electrical activity caused by the impulses that travel through the heart, as detected at the body surface, says Stacie Norris, MBA, CPC, CCS-P, Director of Coding Quality Assurance with Medical Management Professionals in Durham, NC. Those impulses determine the heart’s rate and rhythm.

Diagnostic ECGs may be performed to identify myocardial infarctions, find heart rhythm problems, and detect a variety of other problems such as the effects of a drug overdose. Physicians order diagnostic ECGs based on signs or symptoms that the patient is actively experiencing, says Christina Neighbors, MA, CPC, CCC, ACS-CA, a cardiology coding expert in Tacoma, Wash.

Monitoring ECGs may be used during surgical procedures to keep an eye on the patient’s heart rate, rhythm, and other factors.

Add Cardiac Caths to the Mix

Medicare offers rules for reporting ECGs on the same date as cardiac catheterizations. The gist is that routine ECGs performed during cardiac caths are not billable in addition to the cardiac cath. But you may bill separately for diagnostic ECGs performed before or after the cardiac cath service. Let’s take a closer look.

During cath: Medicare’s Correct Coding Initiative (CCI) manual, Chapter 11, Section I.4, indicates that because ECG monitoring is routinely used during cardiac catheterization, ECG codes aren’t reportable in addition to cardiac cath codes. (The manual is available from the Downloads section at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html)

Here’s the exact quote from the CCI manual, referencing cardiac cath codes 93451-93533 (bold added): "A number of diagnostic and therapeutic cardiovascular procedures (e.g., CPT® codes 92950-92998, 93451-93533, 93600-93624, 93640-93657) routinely utilize intravenous or intra-arterial vascular access, routinely require electrocardiographic monitoring, and frequently require agents administered by injection or infusion techniques. Since these services are integral components of the more comprehensive procedures, codes for routine vascular access, ECG monitoring, and injection/infusion services are not separately reportable."

Dig Into the Diagnostic Exception

Although ECGs that are an integral part of the cardiac cath aren’t separately payable, the patient may have diagnostic ECGs before or after the cath session. Those diagnostic ECGs are separately payable by Medicare when you append modifier 59 (Distinct procedural service) to the ECG code.

The CCI manual, Chapter 11, Section I.16, supports this by stating, "Cardiac catheterization procedures or a percutaneous coronary artery interventional procedure may require ECG tracings to assess chest pain during the procedure. These ECG tracings are not separately reportable. Diagnostic ECGs performed prior to or after the procedure may be separately reportable with modifier 59."

Trap: Don’t confuse standardized patient care with diagnostic ECGs, warns Neighbors. "Some physicians will routinely order an ECG before and after a cardiac catheterization and/or interventional procedure. This is considered standardized patient care."

Helpful: If you’re having trouble determining whether the service performed meets the definition of diagnostic, consider the requirements listed in the National Coverage Determination (NCD) for Electrocardiographic Services (Section 20.15). The NCD manual is available by clicking the link for Publication 100-03 at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html.

The NCD manual states that "EKG services are covered diagnostic tests when there are documented signs and symptoms or other clinical indications for providing the service. Coverage includes the review and interpretation of EKGs only by a physician." So remember that new, unrelated signs and symptoms will drive your decision to capture an ECG with a cardiac procedure, Neighbors says.

Capture Proper Code for Diagnostic ECG

Once you’ve determined that a patient had a reportable ECG on the same date as a cardiac cath, you need to choose the appropriate code. For interpretation and report of a typical 12-lead diagnostic ECG performed in a facility, the appropriate code is 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only). Recall that to override the cardiac cath/ECG edit, you must append a modifier to the ECG code.

Term tip: The code definition refers to "at least 12 leads." For proper coding, you should know that a "lead" and an "electrode" are not the same thing. For instance, providers may refer to 10 electrodes placed on a patient for a 12-lead ECG. To simplify, think of a lead as an electrical view or snapshot of the heart from a particular perspective, creating what the provider sees on the graphic representation. A combination of electrodes can provide a single lead.

The use of "at least" in the 93010 code definition is also important because it means the code is appropriate for 12 or more leads. (For 64+ Leads, see "Category III" on page 42.)

Consequently, 93010 is correct when documentation shows 10 electrodes for a 12-lead ECG or 14 electrodes for a 15-lead ECG because in both cases there are 12 or more leads.

Stay Smart and Cautious for Compliance

Medicare’s rates for the individual components of ECG work (tracing and interpretation/report) aren’t huge at $8 to $10 each. But that doesn’t mean auditors are ignoring ECG coding. For instance, Region A’s RAC DCS is reviewing ECGs reported with cardiac caths for outpatient hospitals. The issue description is: "An overpayment may exist when outpatient hospital providers bill separately for ECGs performed the same date of service as cardiac catheterization procedures. ECGs unrelated (e.g. performed prior to or after) the cardiac catheterization should be billed with modifier 59" (www.dcsrac.com/issuesunderreview.aspx).

Bottom line: On cardiac cath days, experts advise only coding ECGs ordered/documented as diagnostic and performed before or after the cardiac cath. Baseline screenings or monitoring ECGs are not considered diagnostic.