ED Coding and Reimbursement Alert

With the high number of chest pain patients that present in the ED each year, its no surprise that electrocardiograms (ECGs) and chest x-rays make up a large portion of the diagnostic tests ordered. What is surprising is the number of times EDs are denied reimbursement for the interpretation of these tests.

When a patient with chest pain presents in the ED, the main question is usually whether it is cardiac related or musculoskeletal pain. These tests determine which, if either, is the case, says Susan Stradley, CPC, CCS-P, a consultant in the health care division of the accounting firm Elliott, Davis and Company in Augusta, GA, and a former coding supervisor in the emergency department at the Medical College of Georgia Medical Center.

So why are so many EDs having trouble getting paid for reading these tests? The explanation, she says, is two-fold.
First, in many medical centers there is often a dispute over which providers actually read the diagnostic tests: the emergency physicians, or the specialists (radiologists, cardiologists, etc). Second, the emergency physician often may not accurately document the reason for the test, leading the coding and/or billing department to apply the wrong ICD-9 code, Stradley adds.

Considering these challenges, how do ED physicians and departments make sure they get adequate reimbursement for these services? Here are some strategies.

Know if Someone Else is Getting Paid Instead of You

The first thing Id look at is the EOB to see if the claim is getting kicked out because someone else has already been paid for it, Stradley says.

In many hospitals, particularly teaching facilities, a cardiologist or radiologist is expected to re-read the results of ECGs or chest x-rays as a quality assurance measure, she explains. So, youve got two people submitting bills for the reading of the same test.

Medicares stated policy considers the physician who does the evaluation, reads the test, and then uses the results of the test to determine treatment for the patient to be the physician who should receive payment, says Stradley.
In most cases that would be the ED physician, not someone doing a quality assurance read two days later, she notes. But, Medicare is not going to get involved in intra-facility political arguments.

The governments philosophy, Stradley claims, is that they dont want to pay for the ECG interpretation by the ED physician and then pay for the same service performed by another specialist later. Basically, [Medicare is saying] were only going to pay for one, and whoever sends us the bill first gets paid.

The political dispute between non-ED specialists and emergency physicians is a large part of the problem, adds Kenneth DeHart, MD, FACEP, chair of the American College of Emergency Physicians advisory committee on coding and nomenclature. Many hospitals have signed exclusive contracts with cardiologists and radiologists, ensuring them the right to read all of these tests performed at the facility.

Although this shouldnt affect the emergency department, unless the department has a contract specifically excluding the [test interpretation], it is often still an issue, he notes. These disputes must be worked out at the administrative level, the physician adds.

There have been some departments that have negotiated with the radiologists, basically agreeing that if the radiologist doesnt want to stay after 6 p.m., then they contractually agree that the ED physicians will bill for everything after that time, he says.

This still means a loss of revenue for the ED physicians, but, DeHart notes, some ED groups have lost hospital contracts after winning the right to bill for diagnostic test interpretation. Essentially, they won the battle and lost the war.

The quality assurance review of the test is still a valid service, Stradley hastens to add. Its just not the service that provided the treating physician with the information to appropriately care for the patient.
In providing treatment to the patient, ED physicians are the ones doing the work and deserve to be paid for it, she maintains. If these valid situations are not coded and billed, ED physicians will continue to not only lose significant revenue, they will lose the recognition of the work required to interpret these diagnostic tests.

Note: In the event that the ED physician determines the need for a specialist consult to interpret the ECG or chest x-ray and calls the specialist to the ED to read the test, that specialist should indeed be the physician who bills for the test interpretation, Stradley clarifies. Most ED doctors, if they saw something unusual, would call in the specialist to read the test. In addition, if the specialists review of the test changes the diagnosis, then the specialist should bill for the test.

Is the Diagnosis Code Correct?

If the problem is not related to turf conflicts between the cardiologists, radiologists and ED physicians, check to make sure that the diagnosis codes accurately reflect the condition for which the patient was treated and the test was ordered.

If you are doing the test because the patient presents with vague signs and symptoms, such as chest pain or abdominal pain, use those diagnosis codes, Stradley emphasizes. Dont use preventive care or pre-op screening codes.

For example, screening ECGs are usually ordered for patients who will need to undergo anesthesia, but in the ED that is almost never the situation, she notes. In addition, Medicare has deemed screening exams non-reimbursable.

In many caseswhen a patient presents with chest pain, for examplethe physician may examine the patient, order an ECG, not find anything wrong and write down normal exam.

If the coder doesnt recognize what really happened in that situation, he or she will probably code this as a V70.0, the consultant says. And, now they have misrepresented the reason for the visit.

The proper diagnosis code for the visit and the diagnostic test is 786.50 (chest pain, unspecified), states Stradley. The physician might have found nothing wrong, but the reason they did the test is because the patient had chest pain.

The physician should not be penalized financially just because he didnt find anything wrong, she emphasizes. Until they perform the test, they dont know if anything is wrong.

Note: The premise for the V70.0 and this series of ICD-9 codes is that the patient came to the physician thinking that nothing was wrong and the test confirmed that nothing was wrong, Stradley adds. In other settings, a patient might go to the physician for a screening exam,clearance for surgery, for example to rule out the presence of a medical problem.

Does Medicare Recognize the Diagnosis?

Medicare carriers in most states also have lists of valid diagnosis codes that can be matched with diagnostic tests. If the code for a listed diagnosis is not indicated on the form, the claim will not be paid.

In many cases, ED groups can do nothing about this but be aware of it, notes Caral Edelberg, CPC, president and CEO of Medical Management Resources, an emergency medicine consulting firm in Jacksonville, FL. For example, in some states, abdominal pain is not recognized as a diagnosis for an ECG, even though cardiac chest pain doesnt always present in the chest, she explains.

Compounding this problem is the fact that local carriers have different requirements for submitting a claim for diagnostic test interpretation, says DeHart.

Medicare policy requires a written report documenting interpretation of the test results. Some carriers have interpreted that requirement to mean a report on a separate sheet of paper, while others allow the report on the same page with the history and physical, but with a separate signature (by the same physician), etc.

At the national level, HCFAs Negotiated Rulemaking Committee is working on guidelines that would standardize which diagnoses are accepted for which tests, and what documentation justifying medical necessity will be required, says Edelberg. As it stands now, ED coders must check with their local carriers to determine which codes are acceptable.

Code to Indicate Medical Necessity

Physicians, particularly those who work in the ED, need to be educated about the proper way to use diagnosis coding to document the medical necessity for the work they do, says Stradley.

Most doctors have never had any training in coding, and the first feedback they get is when they go to hospitals to work, she explains. The hospital coders will tell them, Weve got to have the most specific diagnosis code possible. For inpatients, they do. But, for an outpatient setting, there is a whole different set of guidelines for how physicians are allowed to code diagnoses.

Basically, in the inpatient setting, a doctor may write down rule-out cancer, for any evaluation service or test used to rule out cancer as a problem, Stradley continues. The hospital coders can code cancer as one of the potential admitting diagnoses or problems.

But, the physician in the ED is only allowed to code what he or she knows at the time the patient is discharged from his or her care, she adds. A vague sign or symptom is a perfectly acceptable diagnosis for this physician, because he or she doesnt know the answer right away. They need to know its OK to write down abdominal pain, because they dont know if its gastroenteritis, colitis, or appendicitis before performing the diagnostic tests.

If you perform the test and still find nothing wrong, you would still use abdominal pain as the diagnosis code, because that was why you performed the test, she states. The patients subjective complaint is sometimes the only thing you have: its the reason the patient came to you.