ED Coding and Reimbursement Alert

Make sure you have the clinical information for assigning the most accurate diagnosis code.

To ensure proper diagnosis coding for electrocardiography, you need to remember two things: specificity and medical necessity.

Rationale: The professional component of interpreting an ECG (93010, Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) is one of the most common diagnostic tests performed by emergency physicians.

During the noninvasive procedure, a patient has electrodes placed on his or her chest, arms and legs to produce an electrical recording of the heart. Technically speaking, the ECG is a graphic tracing of the electrical activity caused by the impulses that travel through the heart that determine the heart’s rate and rhythm as detected at the body surface, says Stacie Norris, MBA, CPC, CCS-P, Director of Coding Quality Assurance Medical Management Professionals in Durham, NC.

ECGs are used in the diagnosis of disorders of cardiac rhythm, anatomy, coronary blood flow, myocardial function, and symptoms related to such disorders. They are also used as an adjunct to the diagnosis of certain drug toxicities and metabolic disorders, Norris adds.

Dx codes crucial to payment: Proper reimbursement for ECGs depends on whether you establish a credible medical necessity for the procedure by applying the correct diagnosis code. These codes tell the payer why the emergency physician performed the ECG. And increasingly, carriers are denying payment if the ICD-9 codes are not specific enough.

Adopt This 3-Step Plan

You can ensure you are coding to the highest possible level of specificity by following a sound coding and assessment process, which Norris offers below:

1. Gather complete information. When you are translating the physician’s encounter information into codes, you need complete information. You may not have enough information to code the services based on the emergency physician’s written notes. For example, if the doctor writes "heart failure" in the patient’s record you may need more information. ICD-9 code 428 (Heart failure) is an incomplete (truncated) code and will be denied because you did not carry it out to the highest degree of specificity. You need the clinical data that will help you determine the type of heart failure and whether it is a confirmed or "rule-out" diagnosis.

Do this: Code 428.0 (Congestive heart failure, unspecified) is a more specific code (if the provider does document "congestive" in their diagnosis) and will allow the ECG to be paid. A rule-out diagnosis may be clinically important to have in the chart, but it will not justify the procedure or service from the insurer’s perspective, and it cannot be coded directly. Consequently, you will have to seek out more information on the specific symptoms from the patient’s chart or by asking the physician. Specific diagnosis coding requires clear access to all the necessary information.

Tip: Due to the nature of the clinical interaction in the ED, it is perfectly acceptable and common to use symptom-based codes. Codes such as unspecified chest pain (786.50) or shortness of breath (786.05) may be all the clinical information available during the emergency physician’s initial treatment. Ideally, diagnosis information should come from the physician’s clear, concise and specific diagnosis written in the patient’s chart, but this kind of detail is often lacking.

2. Use the code with the highest specificity. No matter how well the emergency physician communicates the patient data, you must ensure that you use the right code and that it is being carried to the highest digit possible. This involves not only noting any caution or warning symbols in the ICD-9 manual, but also having a good working knowledge of the terminology for electrocardiograms. If the physician sees a patient for heart failure, you will have to support the diagnosis codes by gathering enough information to know that, for example, the patient has congestive heart failure unspecified (428.0) or left heart failure (428.1).

Where to look: The complete codes for this area are found in the ICD-9 manual under symptoms involving diseases of the circulatory system (390-459).

The simple rule is: Assign three-digit codes only if there are no four-digit codes within that code category; assign four-digit codes only if there are no fifth-digit subclassifications for that category; and assign the fifth-digit subclassification code for those categories where it exists.

Coding example: Here is an example of the type of documentation you want to see from your physicians for a new-onset CHF case for a patient with several different chronic conditions (the appropriate level of history and exam must also be documented):

A 79 year old patient presents to the ED via EMS complaining of chest pain and shortness of breath. The patient states he has been having some increasing orthopnea and exertional dyspnea for the past week and a 2-3 pound weight gain and extremity edema over the past 2-3 days. The patient does have a history of coronary artery disease and diabetes but no history of CHF. A complete chest pain work-up is performed, including chest x-ray, EKG and cardiac labs. A BNP blood test is also ordered to assess the patient’s volume status, as an additional check for heart failure.. The patient is hypoxic on room air, but does improve with supplemental O2. Positive findings in the physical examination include rales and 2+ bilateral extremity pitting edema. Chest x-ray shows pulmonary edema and the BNP is elevated. EKG is normal. The patient is given IV Lasix and also Nitroglycerin paste (for his chest pain) and admitted to the hospital with a diagnosis of New Onset CHF and Chest Pain.

Keep in mind: Although coding to the highest degree of specificity is mandatory, you occasionally have to use an unspecified code -- such as chest pain, unspecified (786.50) or dyspnea (786.00) -- if more specific documentation is not provided or no ICD-9 code exists that matches the ED physicians’ documentation. .

What to report: The ICD 9 coding for the above case would also include one of the few remaining 3 digit codes of 514 for the pulmonary edema and 799.02 for the hypoxia.

3. Run frequent reports. You can see the real evidence of good diagnosis coding by evaluating regular code reports. About every two months, use your billing software to generate a report of the top 50 diagnosis codes and top 50 CPT^® codes each physician used. Carefully review the reports, noting which nonspecific codes the physicians used and how often. Report this information to the doctors and keep track of each report to benchmark progress and trends.

Do this: Additionally, consider reviewing all denials monthly to see if an incorrect ICD-9 code (one that doesn’t meet the requirements for medical necessity) is the culprit. You should also update your reference materials annually to make sure you’re using the most specific and valid code, says Norris.

Doctors only see the small sample presented to them on their encounter form, and many limit their selection to these codes. You should be sure to include all applicable diagnosis codes for possible inclusion on the encounter form to give the doctor the full range of options. If you only include those codes your carriers have indicated show medical necessity, you could be accused of coding for payment, which can be deemed fraudulent.

Look Up Local Policies for Medical Necessity

Medicare carriers assign many common CPT^® codes a list of diagnosis codes that show medical necessity for performing the service. Consequently, you should get carriers’ policies in writing regarding medical necessity for ECGs. You can use them to ensure that the diagnosis you assign supports your physician’s decision to use the procedure.

Watch out: It’s always a good idea to check with your local payer for clarification. However, you should keep in mind that you cannot just pick a diagnosis from the carrier’s policy because it has stated that it will get paid. You must assign ICD-9 codes based on the physician’s documentation.

Also, remind your coders of the importance of carefully reading all of the physician documentation for diagnosis or signs and symptoms that can be coded to support the medical necessity of the claim and also to link the diagnosis to the EKG that will support it, Norris warns.