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 [...]