ED Coding and Reimbursement Alert

Does your chart include the required elements to stand up under audit?

If you're getting repeat denials when your ED physician interprets electrocardiograms [EKG], it's time to stop and ask yourself some critical questions, including whether the documentation meets Medicare's definition of interpretation and whether the notes clearly identify which ED provider did the interpreting and why the EKG was ordered.

Reality: One of the most frequently reported non-E/M services in the emergency department is for EKG interpretation; unfortunately, these codes are also among the most frequently contested services as well.

E/M link: A review of a previously interpreted EKG has value in E/M code Medical Decision Making, but in a totally different way from being separately billable.

Follow these tips from Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates in Baton Rouge, Louisiana, to make sure you are meeting the required documentation for appropriate payment.

Look for Rhythm Report Reason

The CPT® book includes two codes describing interpretation and report of diagnostic cardiographs or the tracings of heart rhythms.

• 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only)
• 93042 (Rhythm ECG, 1-3 leads; interpretation and report only)

The preamble to this code section of CPT® instructs that there must be a specific order for an electrocardiogram or rhythm strip followed by a separate, signed, written, and retrievable report. The need for an electrocardiogram or rhythm strip should be supported by documentation in the medical record.

In the case of the 93042 code, you would not report it when the ED physician simply reviews the telemetry monitor strips taken from a monitoring system. The required specific order for 93042 should be supported by a diagnosis or symptom as the triggering event. To support medical necessity for the service, clinical information demonstrating the need to evaluate for the presence or absence of an arrhythmia, cardiac ischemia, or other cardiovascular problem should be present within the medical record, instructs Edelberg.

In the ED, the physician would not typically report the global codes 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) or 93040 (Rhythm ECG, 1-3 leads; with interpretation and report) because the physician does not typically own the EKG machine nor employ the staff who actually administers the test.

Don't Settle For Payers Bundling EKG Interpretations Into The E/M Service

Code choice aside, some payers refuse to reimburse for diagnostic interpretations in the ED setting, claiming they are bundled into the E/M service and counted in the amount and complexity of data reviewed component of medical decision making, warns Edelberg.

EKG services should be separately reimbursed unless there was simply a "review" of the tracing provided rather than the CPT® defined "separately distinctly identifiable signed written report." CPT® is quite clear in the E/M services guidelines that the actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E/M services. Physician performance of diagnostic tests/studies for which specific CPT® codes are available may be reported separately, in addition to the appropriate E/M code if appropriately documented., she says.

Edelberg' s Critical care tip: Reporting EKGs with critical care services should also be allowed, as long as you report the critical care time net of the time spent providing the separately billable EKG or Rhythm Strip interpretation. Although CPT® does mention EKGs in the Critical Care preamble regarding services bundled into those codes, that reference to is specific to the specific code 99090 (Analysis of clinical data stored in computers e.g. ECGs, blood pressures, hematologic data). The services associated with codes 93010 and 93042 are not specifically listed, so they can be appropriately reported in addition to Critical Care Services.