ED Coding and Reimbursement Alert

Your MI, EKG, cardioversion questions answered

In the emergency department, the physician doesn't always have the time to determine the exact type of heart attack the patient had. But his missing determination doesn't mean you need to fall back on an unspecified myocardial infarction (MI) diagnosis code.

Question: The patient had an MI four weeks ago, and now presents to the ED because of his coronary artery disease and congestive heart failure. How should I report the MI in this situation?

Answer: Because the MI occurred less than eight weeks ago, "you will use the 410.xx series (Acute myocardial infarction) and use '2' as the fifth digit, which is subsequent episode of care," says Becky Tittle, CCS-P, lead coder at Greater Texas Emergency Consultants in Houston. This code choice indicates that the patient has received initial treatment, but the MI is still less than eight weeks old. 

Remember that because the primary reason the patient is in the ED is congestive heart failure (CHF) - not the MI - you should report the MI code as a secondary diagnosis, to show that it could affect the physician's current treatment of the patient.

According to Coding Clinic, if the MI isn't the reason for the admission, then it would not be the principal, but the secondary diagnosis.

Question: The definition of cardioversion 92960 reads in part, "elective, electrical conversion of arrhythmia; external." What does "elective" mean in this definition? And is 92960 included in critical care?

Answer: The definition of "elective" for 92960 (Cardioversion, elective, electrical conversion of arrhythmia; external) is subject to debate. Some experts take it to mean a scheduled procedure. Others take it to mean that the cardioversion doesn't have to be done to save the patient's life.

Take defibrillation, for example, which is not elective. A patient in ventricular fibrillation will die without defibrillation. But a patient with atrial fibrillation at a rate of 180 generally doesn't have to be cardioverted. The meaning of "elective" becomes complicated in a scenario like this one: A patient in a life-threatening arrhythmia is unstable and needs cardioversion. Though the procedure is not defibrillation, it isn't elective cardioversion either. However, if you don't code the procedure as "elective," there's no code for the service rendered.

Your documentation can help you: If the physician's documentation points toward "elective" status, you can get your code cleared. "Elective" documentation might say, "Patient in a fib with rapid response. Will attempt to slow with Cardizem. If unsuccessful, plan cardioversion with sedation." If the doctor has time to sedate the patient, you have further indication that the procedure was "elective." 

If the chart shows the physician was able to obtain informed consent, this is supportive evidence that an elective procedure is being performed, says Michael A. Granovsky, MD, CPC, FACEP, vice president of MRSI in Stoneham, Mass. The chart should indicate that the cardioversion was planned and prepared for - and no, this code is not bundled into critical care.

Question: What documentation must an EKG interpretation include when performed by the emergency department physician?

Answer: According to the American College of Emergency Physicians, "CPT does not clearly state a documentation standard" for these reports. Medicare says that the ED doctor's report must be comparable to that of a specialist in the field and consistent with the service he provided, addressing the physician's findings, relevant clinical issues, and comparative data (if available).

Of note, Medicare has stated that the physician doesn't need to document the interpretive report on a separate sheet of paper for it to be "separately identifiable," a requirement of both CPT and Medicare for payment.