ED Coding and Reimbursement Alert

If you frequently see code 92960 (cardioversion, elective) coming from your ED, youre probably looking at a potential red flag for auditors. This is because ED physicians rarely perform cardioversion. Theyre probably doing defibrillation instead, which is bundled into the CPR code 92950 (CPR, in cardiac arrest). The term elective in 92960s definition throws up a red flag with payers, because ED facilities dont usually schedule procedures for patients with pre-existing conditions. These issues make it more than likely that your facility is coding incorrectly and billing singly for a bundled procedure.

Differentiate Cardioversion and Defibrillation

The difference between cardioversion and defibrillation is in the purpose of the procedure. Defibrillation treats ventricular fibrillation (v-fib). Cardioversion stabilizes rhythms such as atrial fibrillation and atrial flutter.

Defibrillation, whether from v-tac (ventricular tachycardia) when the patient is awake or from v-fib when the patient is in arrest, is included in the CPR code 92950. Defibrillation definitely is not the same as cardioversion, and cardioversion does not link to the CPR codes, says John Turner, MD, PhD, FACEP, medical director for documentation and coding, healthcare financial services at TeamHealth, an ED staffing firm in Knoxville, Tenn.

There are rare situations in which cardioversion is appropriate in the ED, he explains. For example, in most ED situations the physician gives medication to a patient with reasonable blood pressure to help the heart return to a normal rhythm within minutes. This is chemical cardioversion that would be appropriate to bill in the ED.

Occasionally a patient comes to the ED with a rhythm, such as SVT (sinoventricular tachyarrhythmia), is not stable and cannot wait for chemicals to work, Turner says.

The ED physician has to take immediate action to return the heart to a normal rhythm. This is the rare instance in which an ED physician sedates, synchronizes and then electrically cardioverts the patient.

Understanding Elective Provides Another Clue

The term elective is in the code description of cardioversion. However, a person who comes to the ED in a condition that requires heart regulation or stimulation of any kind has not scheduled the procedure: It is not elective. Payers who believe the term elective is reserved for a scheduled procedure take exception to using code 92960 in the ED, says Robert LaFleur, MD, FACEP, president of Medical Management Specialists in Grand Rapids, Mich. However, even the experts disagree on this topic. The elective cardioversion typically is a scheduled procedure for a patient with a pre-existing condition, says Mandy Storman, RHIT, CPC, coding consultant in Health Information Services at Eastern Maine Medical Center, which averages 120 patients a day in Bangor, Maine. When a physician does this type of cardioversion it is synchronized, that is, its done during an R-wave cycle of an EKG.

Coding True Cardioversion

In the rare instances when a true cardioversion is performed in the ED, its important to know the difference between chemical and electrical.

In chemical cardioversion, physicians use drugs [like Adenocard or Cardizem] to bring the heart rhythm back to what it ought to be, LaFleur says. For chemical cardioversion, use the injection codes (90782-90784, therapeutic, prophylactic or diagnostic injection; subcutaneous or intramuscular; ... intra-arterial; ... intravenous) or IV infusion codes 90780, 90781 (IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour; ... each additional hour) with the E/M level appropriate for the supporting documentation.

In these instances, the E/M level most likely would be five because of the criticality and complexity of the situation. So, you would accompany the code reported for the cardioversion with 99285 (emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patients clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity) or critical care 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 ( each additional 30 minutes [list separately in addition to code for primary service]).

Turner explains that an ED situation in which cardioversion (92960) takes place would be classified a level five or critical care as long as the documentation supports it. Code 92960 is not bundled into 99285 for critical care and should be billed separately for Medicare and commercial carriers.