ED Coding and Reimbursement Alert

Does your chart trace a clear picture of a separately identifiable service?

It's happening again. Payers are aggressively bundling the interpretation and report of diagnostic EKGs into the ED E/M level of service. Although the reimbursement for code 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) only pays $8.60 in the 2014 Medicare fee schedule, that amount adds up over the course of a year. Check out these tips to help jump start your payments for this common ED service.

First, Review the Fundamentals

For a service to be payable, it has to be clear that it was provided and that it was medically necessary. 

Is your chart documentation clear that the emergency physician actually personally provided the separately identifiable, signed written interpretation and report required? Is there a diagnosis listed that justifies the medical necessity of the test? Is your written report similar to an expert in the field with comments about specific relevant clinical issues, study findings such as rhythm, rate, and axis and comparative data if available? If not, these may be the reasons for your denials, says Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, Chief Executive Officer of Edelberg Compliance Associates

Are There Multiple Bills?

Assuming you clear those hurdles and your documentation of the interpretation and report is airtight, it may be payer policy driving the denial. Most payers will only pay for one diagnostic interpretation of a single test. 

If both your emergency physician, and a cardiologist providing quality over reads, bill for interpretations of the same EKG, that could be case for the denial. Medicare makes the distinction of wanting to pay for the interpretation that was "contemporaneous" with the diagnosis and treatment of the patient. 

If a Medicare carrier does receive multiple bills for the same interpretation and report for a single diagnostic test, the carrier is to pay for the interpretation and report that directly contributed to the patient's diagnosis and treatment.  That would typically be from the treating emergency physician; however, a radiologist's respective interpretation and report could meet this requirement if a written or an oral report followed by a subsequently written interpretation and report was conveyed to the treating physician before the end of the patient encounter, Edelberg adds.

Go To The Source For Support Of Your Position

CPT® contains specific language making it clear that "The actual performance of and/or interpretation of a diagnostic test ordered during a patient encounter are not included in the levels of E/M service. ... The physician's interpretation of the results of diagnostic tests /studies, (i.e. the professional component) with preparation of a separate distinctly identifiable signed written report may be reported separately."

The Correct Coding Initiative (CCI) edits do not bundle 93010 into the 99281-99285 ED E/M codes. EKG interpretation is also not bundled into critical care codes as are interpretations of a chest x-rays according to language in the CPT® critical care section. 

The bottom line: Armed with these facts, you should be able to successfully appeal routine bundling of EKG interpretations into your E/M codes, says Edelberg.