ED Coding and Reimbursement Alert

If you're not clear on what separates cardioversion from defibrillation, let alone what separates one cardioversion from another, you will never receive payment for you physician's work.
 
Accurately identify these procedures in the ED by focusing on individual, clinical details and do this before you even think about coding. (For more on the codes for these procedures, refer to "How to Capture Pay for Cardioversions, Defibrillations".)
 
Cardioversions and defibrillations solicit denials when coders don't adequately understand the physician's notes and accurately distinguish between these two pacing procedures. Often, they're reported interchangeably or not at all. Throw in the added complication of "chemical" versus "electrical" cardioversions and the elusive "elective" cardioversion, and you have confusion that's bound to muddle claims.
 
But if you learn to distinguish between each procedure, coding them is easy, and you will secure payment, even if it's minimal experts will tell you how.

Look for Documentation Hints to Separate Defib From Cardio

 First things first: Cardioversion is not the same thing as defibrillation, says Robert La Fleur, MD, president of Medical Management Specialists in Grand Rapids, Mich., so you shouldn't report them the same way.
 
Defibrillation, when physicians use carefully controlled electric shock to restart or normalize heart rhythms, is always an emergency procedure, says Norma Herzog, CCS-P, NREMPT-P, the compliance manager at Med-Data Inc. in Seattle. The patient who receives this service has no pulse and is in ventricular fibrillation (VF) (427.41), she says. A physician will sometimes defibrillate a patient in apparent asystole (427.5) because the rhythm may be a fine VF, and you have nothing to lose in trying the procedure, she adds.
 
On occasion, physicians also use defibrillation for patients with ventricular tachycardia when the patient has no pulse (427.1), La Fleur says, but most often for defibrillation, "These patients are dying."
 
The following clues in the documentation may also indicate that the physician performed defibrillation, Herzog says:
 

 the physician delivers the shock at any point in the cardiac cycle (the synch mode on the machine is turned off, La Fleur says)
 

 there is no sedation (the patient is almost always unconscious)
 

 a medical team also renders cardiopulmonary resuscitation (CPR) (92590) (there are pulseless cardiac rhythms).
 
Pay attention to this CPR detail. The shortcut way to know whether your physician performed defibrillation and didn't perform cardioversion is to check for indications that medical personnel also performed CPR. If CPR was in progress, the physician most likely gave defibrillation shocks, Herzog says.

Break Down Cardio Into Chemical and Electrical

Contrary to defibrillation, cardioversion is the conversion of one cardiac rhythm to another or an electrical pattern, usually an abnormal rhythm to normal.
 
Look for the following (limited set of) conditions to identify cardioversion in your physician's notes:
 

 atrial fibrillation, 427.31
 

 atrial flutter, 427.32
 

 paroxysmal supraventricular tachycardia (PSVT), 427.0
 

 wide-complex tachycardia of uncertain type, 427.2
 

 ventricular tachycardia, 427.1.

If your physician performed cardioversion, that procedure was either chemical or electrical. Distinguish between the two by sifting through details in the documentation.
 
A chemical cardioversion treats a patient with PSVT, who is not considered unstable, Herzog says. A physician will frequently attempt a vagal maneuver before giving a round of chemical cardioversion.
 
Chemical cardioversion treatment involves, for example, Adenosine to treat supraventricular tachycardia, La Fleur says.
 
The recipient patient will not yet be truly hemodynamically unstable but may have early signs of the following, which you should look for when reviewing your physician's notes:
 

 shortness of breath, 786.05
 

 decreased level of consciousness, 780.02
 

 low blood pressure (BP), e.g. 458.9
 

 shock, e.g. 785.51 (Cardiogenic shock)
 

 pulmonary congestion, e.g. 770.0 (Congenital pneumonia)
 

 congestive heart failure (CHF), 428.0
 

 myocardial infarction (MI), 410.91.

Some of these more severe symptoms warrant strong consideration for using an electrical cardioversion, a procedure explained below, instead of a chemical cardioversion. The more severe the symptom, the more likely the physician will resort to electrical cardioversion instead of chemical cardioversion because the latter applies to symptomatic but not yet unstable patients. If the patient has early signs of the conditions on this list, the physician would consider chemical cardioversion, but full onset of these conditions, increasing in severity, suggests electrical cardioversion.

Most Often, Do Not Elect 'Elective'

 Unstable ED patients not responding to the drugs used in chemical cardioversion will receive electrical cardioversion, which is considered an emergency procedure, Herzog says. The electrical cardioversion used in this more common ED circumstance, however, is not the elective, electrical cardioversion procedure described in CPT 92960 (Cardioversion, elective, electrical conversion of arrhythmia; external).
 
Elective (electrical) cardioversions do not generally occur in the ED because there's not sufficient time to explain the procedure to the patient and obtain the patient's consent, La Fleur says. The procedure generally treats patients who are relatively stable, he adds.
 
But don't entirely rule out reporting elective cardioversions for the ED. The meaning of "elective" is a "subject of debate," La Fleur says.
 
Some experts interpret "elective" as "scheduled." Elective cardioversion is a "planned event," says Laurel Green, CPC, the manager of coding quality and training at Med-Data Inc. in Seattle. A physician performs elective cardioversion for atrial fibrillation or atrial flutter if anti-arrhythmic drugs have failed to convert the heart back to normal sinus rhythm or if the patient is hemodynamically unstable, she says. A patient undergoing this procedure is usually not in the ED because the procedure generally entails fasting after midnight the day before and starting an intravenous line as preparatory work. This procedure usually occurs in an intensive care unit (ICU), a coronary unit or any other outpatient area that houses the necessary equipment, such as the cardiac monitor or a crash cart, she says.
 
Other coders interpret "elective" in the ED to mean the attributed service isn't necessary to save the patient's life but doesn't have to be scheduled, La Fleur says. Take, for example, the patient with atrial fibrillation at a rate of 180. This patient generally doesn't have to receive cardioversion, so there are other treatment options. Cardioversion may be "elective" in this case.
 
Other patients in stable conditions in the ED may have elective cardioversion performed, Herzog says. These patients will have a detectable pulse, and the cardioversion will deliver a shock on the "R" portion of the QRS complex (the deflections in an EKG tracing that represent the ventricular activity of the heart) on the cardiac monitor, which explains the name "synchronized cardioversion," she says that is, when the defibrillator is in the synch mode, La Fleur says.
 
Your physician should provide documentation that suggests that the treatment was, in fact, elective. Do not expect notation of extensive preparatory work and a considerable time frame that a scheduled event usually prescribes. Instead, expect documentation showing that the ED physician obtained informed consent from the patient and discussed the risks and benefits of the procedure as well as notation that the patient received sedation to make the procedure more comfortable. These elements paint the picture that, although an emergency procedure, this cardioversion was still a planned treatment.
 
Because this debate about what qualifies as elective cardioversion in the ED has no resolution, you should ask your physician to document specifically whether the cardioversion was elective, Herzog says.