ED Coding and Reimbursement Alert

When a patient with a potential cardiac problem is examined in the emergency department (ED), the emergency physician often orders an electrocardiogram (ECG) and interprets the results to determine whether there is indeed a heart problem, and the nature of that problem. When the physician performs the actual interpretation of the test that he or she ordered, the physician can bill for this in addition to the evaluation and management (E/M) service delivered to the patient that day.

However, third-party payers require physicians to provide specific evidencein the form of a written reportthat the service they provided to the patient was the actual interpretation of the ECG and not just a review of data.

There must be a formal report in the patient record, and it must be detailed, advises Jan Loomis, director of coding and documentation for TeamHealth West, Inc., an emergency physician staffing company in Pleasanton, CA. It is the same detail in the report that a cardiologist would do on a final read. It is not a quick read, but a detailed interpretation.

Documentation Is Crucial to Payment

Some ED groups have had payments for these services deemed invalid in an audit due to lack of appropriate documentation, says Loomis.

According to the Health Care Financing Administrations (HCFA) Medicare rules, the documentation must include a separate report of the physicians interpretation.

Tip: The HCFA requirements for billing ECGs performed in the emergency room can be found in the Dec. 8, 1995, Federal Register. The requirements were published as part of the bulletin: Medicare Program, Revisions to Payment Policies and Adjustments to the Relative Value Units under the Physician Fee Schedule for Calendar Year 1996. The portion concerning ECGs begins on page 63130 of the document. (See insert.)

This requirement does not mean necessarily that the report must be on a separate piece of paper, but it must be separate from the rest of the documentation of the patients visit, says Pat Moore, vice president of reimbursement services for Healthcare Business Resources, Inc., an emergency medicine billing company in Durham, NC.

The HCFA rule does not say it must be on a separate page, it just has to be a separate report, she explains. So you could have the ECG interpretation written on the emergency record. But you must say ECG interpretation and then give the separate report. That is how I interpret the HCFA requirements.

Moore also notes that in a meeting with physician representatives, then-HCFA Administrator Bart McCann was asked about the rule and stated that the report did not have to be on a separate page.

What Should a Formal
ECG Interpretation Include?

Loomis says that the report should include information about the actual results of the ECG and how the physician interprets these findings to establish a diagnosis.

You should include specific information about ST segment intervals, rate, rhythm, axis intervals, etc., Loomis says. You should not have a report that just indicates the final determination, such as ECG normal.

Many groups use a standard form on a stamp that prompts physicians to include the needed diagnostic information, says Loomis.

Moore concurs, advising that her company has developed a short form to ensure that the physicians know to include sufficient detail.

We kind of divided the interpretation into sections. We have space for comments on the rate, rhythm, axis interval, the QRS-T wave comments, any acute or chronic changes, comparison with the most recent tracing and the clinical findings or diagnosis. Not every one of those elements is necessary, but there should be enough information there to tell you what is pertinent about that ECG, says Moore.

Although it is not yet a HCFA requirement, Moore advises physician groups who want to bill for ECG interpretations to find out their hospitals requirements for a formal report of a diagnostic test interpretation and to use those rules as a basis for developing their own requirements for the written report (see related story on page 91).

Report the Correct Code

In addition to ensuring appropriate documentation of the ECG interpretation, ED coders must choose the correct code for the physicians service, advises Loomis.

In the physicians office setting, the standard code for the performance of an ECG that includes the physicians interpretation and report is 93000 (electrocardiogram, routine ECG with at least 12 leads; with interpretation and report). This code is inappropriate in the ED setting, however, because the physician group does not own the equipment, the hospital does, she indicates.

The RVUs assigned to this code are weighted to include reimbursement for the office expense and overhead involved in maintaining the equipment. It is inappropriate for the emergency physician to receive payment for that.

For an ECG performed and interpreted in the ED, the physician should report the code 93010 (electrocardiogram, routine ECG with at least 12 leads; interpretation and report only).

Coding Rhythm Strips?

Because every 12-lead ECG also includes a three-lead ECG, known as a rhythm strip, some coders are choosing to report 93042 (rhythm ECG, one to three leads; interpretation and report only) when the documentation is insufficient to support coding the interpretation of the entire 12-lead ECG.

The relative value units for 93042 are lower than
for 93010, as are the requirements for documentation,
but the group would still get partial reimbursement for
the interpretation.

Opinions about the validity of this practice are mixed. In 15 years, I have never seen anyone get audited by Medicare for that, says Loomis. I have seen the reverse, where you are coding the 12-leads, when in fact you have been doing strips off the monitorso you are upcoding. I have never seen an implication for downcoding. The only thing that I do understand is that Medicare does not want us to use both codes together. So, if you have done a strip off the monitor and performed a 12-lead, then pick one. But you cant report both.

Moore feels that it is incorrect to report a code for a rhythm strip, when, in fact, the physician performed and interpreted a 12-lead ECG.

I dont believe you should bill a lesser code, even though every ECG would actually have a rhythm strip, I would not do that, she advises.

I believe that in a case like that, what I have found among the clients that we bill for, the doctor doesnt have enough documentation for the ECG interpretation because they are at a hospital where they have a cardiologist billing for the ECGs interpretations. (See related article below on who should bill for ECG interpretations.)

In that case, it would be fraudulent for the physician to report a code for the rhythm strip, knowing that another physician intended to bill for the actual 12-lead interpretation.