ED Coding and Reimbursement Alert

Split these procedures apart to prevent denials.

Deciphering clinical chart details to figure out how to identify services in the ED can challenge the most experienced ED coders. That’s especially true for cardioversions and defibrillations, which can trigger denials when coders don’t know how to read the reports and accurately distinguish between them, in which case they’re reported interchangeably or not at all. With the added complication of "chemical" versus "electrical" cardioversions and the elusive "elective" cardioversion, it is no wonder there is often confusion.

Good news: But if you learn to distinguish between each procedure before you properly code them, you will secure payment, even if it’s minimal -- here’s how.

Look For Documentation Hints To Separate Defibrillation From Cardioversion

First things first: Cardioversion is not the same things as defibrillation, emphasizes Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, an ED coding and billing company in Bedford, MA

Defibrillation, the use of an electric shock used to restart or normalize heart rhythms, is always an emergency procedure, says Granovsky. The patient who receives this service has no pulse and is typically in ventricular fibrillation (VF) (427.41) (sidebar-ACLS protocol does not support defibrillation for PEA) he explains. A physician will occasionally defibrillate a patient who is ultimately determined to be in asystole (427.5) because the patient’s rhythm was potentially suggestive of fine VF, Granovsky adds.

Defib clues: On occasion, physicians also render defibrillation for patients with ventricular tachycardia (VT) when the patient has no pulse, so called pulseless VT. Below are additional clues that the procedure is defibrillation, according to Granovsky:

• the physician delivers the shock at any point in the cardiac cycle.
• there is no sedation (the patient is unconscious).
• a medical team also renders CPR (92590) (there are pulseless cardiac rhythms).

Pay attention to this CPR detail. The shortcut way to potentially know whether your physician performed defibrillation ��" and didn’t perform cardioversion ��" is to check whether CPR was ongoing immediately before the shocks were provided. If CPR was in progress, then defibrillation shocks were likely given, Granovsky adds. Importantly, there is no CPT^® code to report defibrillation as a procedure performed in isolation.

Watch Tor these Diagnoses For A Clue About Cardioversion

As opposed to defibrillation, cardioversion is the conversion of one cardiac rhythm to another or electrical pattern, usually an abnormal one to normal. It treats a variety of conditions, including:

• atrial fibrillation (427.31)
• atrial flutter (427.32)
• paroxysmal supraventricular tachycardia (PSVT) (427.0)
• paroxysmal tachycardia unspecified (427.2)
• paroxysmal ventricular tachycardia (427.1).

Break Down Cardio Into Chemical And Electrical

If your physician performed cardioversion, that procedure was either chemical or electrical. Distinguish between the two by sifting through details in the documentation.

The skinny: A chemical cardioversion may be used to treat a patient with PSVT, who is not considered unstable, Granovsky explains. A physician will frequently attempt a vagal maneuver before giving a round of chemical cardioversion, and the recipient patient may have early signs of the following, but has not become truly hemodynamically unstable.

Most of these listed symptoms, if severe or progressing, would warrant strong consideration of electrical cardioversion. Chemical cardioversion is employed in symptomatic, but not unstable patients, Granovsky adds.

• shortness of breath, 786.05
• Low blood pressure, 458.9

Chemical cardioversion treatment involves, for example, Adenosine to treat supreventricular tachycardia, Granovsky offers.

More details: ED patients not responding to the drugs used in chemical cardioversion may receive electrical cardioversion, which is considered a more urgent procedure, Granovsky states. The electrical cardioversion used in this more common ED circumstance, may not always be viewed as the elective, electrical cardioversion procedure described in CPT^®: ¤ 92960 (Cardioversion, elective, electrical conversion of arrhythmia, external). Remember the target symbol "¤" means it appears on Appendix G and the moderate sedation is bundled into the code, not separately reportable

You Would Typically Not Elect ‘Elective’

When emergency physicians perform electrical cardioversions, as noted, these services are fairly urgent, though they often do involve a discussion with the patient. Elective cardioversions occur in the ED when there’s sufficient time to explain the procedure to the patient and potentially obtain the patient’s consent, Granovsky explains. The procedure generally treats patients who are relatively stable, but may rapidly worsen. Reporting elective cardioversions for the ED is not forbidden. It often depends on the interpretation of the word "elective," Granovsky explains.

Understand the difference: Some experts interpret "elective" as "scheduled." Elective cardioversion is a "planned event. 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, Granovsky states. A patient undergoing this procedure is usually not in the ED because the procedure usually entails fasting after midnight the day before and starting an intravenous line as preparatory work, he summarizes. This procedure usually occurs in an Intensive Care Unit, a Coronary Unit or any other outpatient area that houses the necessary equipment (i.e., the cardiac monitor, a crash cart), he adds. You may report code 92960 if it accurately describes the service provided, he adds.

Other experts interpret "elective" in the ED to mean the attributed service doesn’t have to immediately curtail an actively progressing deadly rhythm -- and it doesn’t have to be scheduled, Granovsky says.

For instance: Take, for example, the patient with atrial fibrillation at a rate of 180. For this patient, there are other treatment options, generally involving drugs such as Cardizem first. However, if these pharmacologic interventions fail, the physician may decide to employ cardioversion, Granovsky explains, so selecting cardioversion may be "elective" in this case.

Patients without VF or pulseless VT in the ED may have elective cardioversion performed. These patients will typically have a detectable pulse, and the cardioversion will deliver a shock on the "R" portion of the QRS complex on the cardiac monitor, which explains the name "synchronized cardioversion," Granovsky summarizes.

What to look for: Documentation to suggest that the treatment was elective cardioversion would include the ER physician obtaining informed consent from the patient and discussing the risks and benefits of the procedure, as well as the patient potentially receiving sedation to make the procedure more comfortable. These things paint the picture that, although rapidly necessary, this was a planned treatment.

Do this: Because this debate between what qualifies as elective cardioversion in the ED has no resolution, you should ask your physician to document specifically if the cardioversion was elective, Granovsky instructs.

Be "Clear" When Selecting The Codes For Cardioversion

Once you’ve distinguished between cardioversions and defibrillations, chemical and electrical, elective and emergency -- then the coding comes easily.

The downside: Most of these procedures don’t have specific CPT^® codes. If the physician performs defibrillation, that work is bundled into the CPR code 92950 (Cardiopulmonary resuscitation [e.g. in cardiac arrest]), Granovsky states.

There are no specific codes for elective chemical conversion either, says Granovsky. You can report the occasional ED elective cardioversion, 92960, again preferably documented as such, and when electrical. If applicable, remember to subtract out from critical care time the physician’s time spent rendering elective cardioversion. Any time spent in concurrent procedures for the patient does not count as critical care time, he adds.