Maximize Reimbursement for ECG Overreads
Published on Sun Aug 01, 1999
Cardiologists often review ECGs at the request of other physicians or hospitals who want an expert second opinion on the data. In fact, the Joint Commission on Accreditation of Hospital Organizations (JCAHO) requires hospitals to do ECG overreads, where a cardiologist gets an ECG a few days after it is obtained in the facility and reviews it. And sometimes, an attending family practitioner or internal medicine physician, for example, may perform and interpret the ECG and then ask a cardiologist for an overread to ensure they havent missed anything.
But billing for re-reading ECGs can be a real headache for cardiologists. Incorrect claims can result in either insufficient reimbursement, or, in the case of overpayment, can spur an audit or worse.
The issue is not whether ECG interpretations should be performed or reimbursed, assuming that diagnosis codes provided with the claim support the medical necessity of the test. Rather, at issue is who should receive payment for the interpretationthe physician who ordered it and first analyzed the test or the cardiologist who was later consulted. Also in question is who should pay for the overread, the physician or hospital that seeks the consultation, or the insurance carrier.
The Health Care Financing Administration (HCFA), which administers Medicare, has settled the second issue. Section 15023 of the Medicare Carriers Manual, issued in July 1997 and not changed since, instructs Medicare carriers to pay for only one interpretation of an ECG or x-ray procedure furnished to an ER patient.
Process Overread Claims Quickly
The first question, however, has been thornier. The same HCFA notice cited above instructs carriers to pay for the first bill received when multiple claims are submitted for one interpretation. The guideline then states: Pay for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient. If the first claim received is from a [cardiologist], pay the claim because you would not know in advance that a second claim would be forthcoming. When you receive the claim from the ER physician and can identify that the two claims are for the same interpretation, determine whether the claim from the ER physician was the interpretation that contributed to the diagnosis and treatment of the patient and, if so, pay that claim. Determine that the [cardiologists] claim was actually quality control and institute recovery action. The guidelines also urge Medicare carriers to encourage the two parties [ER physician and cardiologist] to reach an accommodation as to who should bill for these interpretations.
Most third-party payers have followed HCFAs lead on this issue.
Note: HCFA no longer considers physician specialty or whether a hospital has designated a particular department the official ECG biller as factors in determining which claim to pay. [...]
