Cardiology Coding Alert

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.

For example, say an ED physician sees a patient in the ER on January 1 and orders an ECG. The ED physician reviews the ECG, treats and discharges the patient. A cardiologist overreads the ECG, then bills the Medicare carrier for CPT code 93010 (electrocardiogram, routine ECG with at least 12 leads; interpretation and report [only]). Note that the claim includes a written report. Modifier -26 (professional component) would not be used because 93010 is used for interpretation and report only. In this scenario, the carrier is instructed to pay the cardiologists claim because it is the first bill received.

Note: Code 93000 (electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) is filed when the same physician performs both technical and professional components. Code 93005 is for the tracing (technical) component only, without interpretation and report.

However, if the ED physician who first saw the patient bills 93010, dated January 1, and if there is no reason to think that a complete, written interpretation was not performed, that doctors claim will be reimbursed, because it is the first claim received. The cardiologists subsequent claim, dated January 3, will be denied, HCFA says, unless there are unusual circumstances that are well-documented, such as a questionable finding on the ECG that requires an expert consultation or a changed diagnosis that resulted from the cardiologists overread.

Expanding on the previous example, say the ER physicians interpretation of the ECG correctly determined that the patient did not have an arrhythmia, but the cardiologists overread found something else that required more tests. The cardiologist would bill 93010 and also attach modifier -77 (repeat procedure by another physician) to indicate that the cardiologists overread resulted in a second diagnosis.

If both physicians bill for the ECG simultaneously and the documentation establishes that the cardiologists interpretation was available to the treating ER physician (either verbally or in writing) in time to contribute to the diagnosis and treatment of the patient, the cardiologists claim will be paid and the ER physicians claim will be denied as not reasonable and necessary, HCFA says.

It Pays to Communicate

Given the fact that payers usually only will pay for one ECG interpretation, physicians need to communicate with each other whos going to do the billing and whos going to get the credit.

One chronic problem with billing overreads is that the cardiologist has to rely on another physician or a hospital for billing information, including the name and address of the carriers. The other doctor or facility may provide no chart, as well as nothing in writing guaranteeing payment. Consequently, the cardiologist may end up having to bill a patient who resents receiving a bill from a physician he or she has never even seen.

Sabina Valentine, CPC, a coder with New Brunswick Cardiology Group in New Brunswick, NJ, says that whoever does the original ECG should let the patient know there may be a subsequent bill from the cardiologist who checks the ECG. But in reality, that rarely happens.

Valentine suggests that a cardiologist asked to do an overread should have an agreement with the requesting physician that specifies reimbursement and other terms for such a service. Valentine also urges cardiologists to talk to the hospital director about separate payment for overreads if such claims are denied due to lack of medical necessity.

Cardiologists also need to communicate better with payers, says Cynthia Swanson, RN, CPC, a management consultant with Seim, Johnson, Sestak, Quist, LLP, an accounting and consulting firm in Omaha, NE. When a physician bills for an ECG interpretation, the claim must be supported by documentation, Swanson says. This should include a separate note to indicate what was interpreted. An interpretation and report should address the findings, relevant critical issues and comparative data (when available).

Handwritten notes by the physician on the original ECG strip are considered acceptable documentation, as long as the physician signs off on the strip, Swanson says.

Section 15023.A of the Medicare Carriers Manual instructs carriers to distinguish between an interpretation and report and a review of an ECG. According to HCFA guidelines, a review without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service, since the review is already included in the emergency department E/M payment.

For example, a notation in the medical records saying ECG-normal would not suffice as a separately payable interpretation and report of the procedure and should be considered a review of the findings payable through the E/M code.

To date, many cardiologists have continued to be paid for overreads because some ER physicians did not submit their own bill for the interpretation or because some carriers have been paying the first bill in and it was theirs. But if Medicare decides to enforce its guidelines more stringently, providing supporting documentation will become even more critical in obtaining payment, as will alternative billing arrangements with hospitals and physicians requiring a cardiologists expert consultation.