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ED Coding and Reimbursement Alert

Be the First to the Finish Line With EKG and X-Ray Interpretations

Published on Sun Dec 01, 2002

The most effective way to code EKG and x-ray interpretations for the emergency physician requires more than just deciphering rules it takes speed.

Down in the coding trenches, you're less concerned with political crossfire than with clearing claims for reimbursement. Here are tips for coding and billing EKG and x-ray interpretations by the ED physician, despite the current policy controversy.

You must have documentation of a "contemporaneous" interpretation to trigger Medicare payment for the professional interpretation of an EKG and x-ray rendered by the ED physician. In other words, you should expect payment if documentation indicates that the physician's reading made a timely and direct contribution to the diagnosis and treatment of the patient. An interpretation provided "days or hours" after the patient goes home does not fit CMS' requirement that the interpretation be performed "contemporaneously" with the diagnosis and procedure, according to a letter sent by Paula C. Ohliger at Foley & Lardner attorneys (San Francisco) to the associate executive director of policy at the American College of Emergency Physicians.

As with all claims, you have to show medical necessity. The physician's diagnosis must justify the interpretive test, such as an EKG, says Tamra McLain, CPC, coding manager for HRA Medical Management Inc. in the San Diego area. For a list of Medicare's diagnosis codes, check with your local carrier or go to www.lmrp.net.

Plow Ahead, If You Have the Documentation

Submit the interpretation claims if they contributed directly to the diagnosis and treatment of the patient, even if your specialist might bill for the same reading you've reported.

Even though CMS states that it will deny your claim and pay the specialist's contemporaneous interpretation, don't throw in the towel. Under many circumstances, the ED is allowed to receive payment for interpretive services, says James Blakeman, senior vice president of Healthcare Business Resources in Bala Cynwyd, Pa.

You forfeit payment if you assume the radiologist and cardiologist automatically receive payment for interpretations. If a cardiologist interprets an EKG seven days after the patient leaves the ED, and the emergency physician provided the EKG interpretation that helped with diagnosing and treating the patient, then the ED physician's claim not the specialist's qualifies for payment.

You must follow payers' official policies for billing ED interpretations, but if you add these practical hints to your repertoire, you're more likely to see results:

  • Get to the line first, lest you be disqualified. Interpretation payments go to the swiftest, so get your claims in on time. The sooner they cross the payer's line, the more chance they have of passing the "truly contemporaneous" criterion. Your timely claim tells the payer or carrier: Only the interpretation given in time for a patient's diagnosis in the ED could have reached the payer so fast.

    Sometimes, however, Medicare carriers practice the "don't ask, don't tell" policy for contemporaneous status, Blakeman says. They don't ask for explicit proof that the reading was done in time for the patient's diagnosis and treatment. If carriers don't always check the time of the specialist's reading, they'll probably pay the first claim, so filing immediately is always your best bet.

  • Check the hospital policy. The common obstacle to hurdle is not always the insurer: Watch out for your hospital policy.

    When hospitals generally bill for emergency department services, they sometimes refuse to let you bill for interpretations rendered by the ED physician, says Gregory D. Hobbs, MD, senior vice president of Superior Consultant Inc., in "Current and Future Issues in Emergency Medicine," featured on the Bon Secours Health System Web site's "Technology Early-Warning System." The hospitals allow cardiologists and radiologists to bill for interpretations "even when the interpretations are not rendered contemporaneously" with the EKG or x-ray, he adds.

    If you can verify that your hospital is blocking reimbursement for the contemporaneous claim in the face of specialists' noncontemporaneous claims, consider notifying your medical directors. Your hospital should "ensure" CMS policy, Hobbs says.

  • Negotiate with your radiologists for x-ray reimbursement. Since current CMS policy doesn't explicitly resolve the deadlock, take matters into your own hands. Confront your radiology department to create a mutually beneficial payment plan, Blakeman says.

    Ask radiologists to agree to one of two bargains, he suggests:

    1. Full-time, on-site radiologists: The radiology clinic receives full payment for the x-ray interpretation if it stations a radiologist in the ED for 24 hours, seven days a week, who will interpret x-rays ordered by the ED physician in time to contribute directly to diagnosis and treatment.

    2. Split-payment arrangement: The emergency department receives full payment for when the radiology clinic is closed, and the radiology department receives full payment for readings done during their business hours.

    Learn from successful professionals who have extended the olive branch. A California coding office that bills for an ED that is visited frequently by Medicare and MediCal patients arranged a split-pay plan with its radiologists. For x-ray readings done by ED physicians between 10 p.m. and 8 a.m., the office codes and bills for the ED physician, says coding office manager Tamra McLain, CPC, with HRA Medical Management Inc. in the San Diego area. During the other hours when radiologists are available, the office doesn't bill for ED interpretation claims.

    If you get the split-pay agreement in writing, coders have a policy to follow when determining when the ED physician deserves payment, she says. To determine when to code, her employees verify that the patient was in the ED and check the time the x-rays were read. Approach the appropriate medical directors with this success story.

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