ED Coding and Reimbursement Alert

Getting paid for electrocardiogram (ECG) and x-ray interpretations has always been a problem for emergency physicians. Many hospitals have contracts with their cardiology and radiology groups stipulating that these specialists will perform all interpretations of the diagnostic tests in their specialty (radiologists for x-rays and cardiologists for ECGs) performed at the hospital.

When the tests are performed as an inpatient service, there is little dispute. In the emergency department (ED), however, getting a radiologist or cardiologist to perform an interpretation of the diagnostic test in sufficient time to determine treatment for the patient may be difficultfor example, when patients are treated at night or on weekends.

In many cases, the ED physician must interpret the results of an ECG or x-ray and make a treatment decision. A designated specialist often reviews the test the next day or even later to double-check the results. The question is, which physician should get paid for the test interpretation?

Treatment Decision-maker Is Deciding Factor

According to the Health Care Financing Administrations (HCFA) final rule on payment for ECG and x-ray interpretations in the ED, the physician who performs the interpretation that guides treatment decisions for the patient should be paid. HCFA also has stated, however, that the administration is not responsibile for determining whether the physician submitting the claim is the one who should be paid. In essence, it is the individual physicians responsiblity to determine who should submit a claim for this service.

Note: For more information on this subject, please see Get Paid for ECG and X-ray Interpretations, in the December 1998 ED Coding Alert.

I think that few emergency physicians actually bill for x-rays and ECGs when they should, notes Pat Moore, vice president for reimbursement services at Healthcare Business Resources, Inc., an emergency medicine billing company in Durham, NC. If groups are allowing the specialists to bill for quality assurance (QA) overreads as an interpretation, that is incorrect. HCFA has said that QA overreads are a Part A service and the facility is reimbursed under Part A Medicare.

But Medicare Part B should not be paying for this service. Part B should be paying only for x-ray and ECG interpretations that guide patient care.

Second Opinion Exception

Moore explains that it is important to differentiate between a routine QA overread and a second opinion interpretation that is paid for under Part B.

ED physicians should also remember that it is entirely appropriate for them to request a second review of the test if they feel it is warranted, she says. And that service will be paid for by Medicare. In that case, the specialist should report the same interpretation code, 93010 (electrocardiogram, routine ECG with at least 12 leads; interpretation and report only), with modifier -77 (repeat procedure by another physician).

For example, the emergency physician performs an ECG interpretation in the emergency room. But to be sure of his decision, he requests a second opinion from the cardiologist on-call. As long as the interpretation is contemporaneous to the episode of patient care, then it also can be paid, notes Moore, referring to the language in the HCFA final rule. The ED physician would report 93010, and the cardiologist would report 93010-77.

Contemporaneous means that the specialist rendered the interpretation in time to affect patient care, not retrospectively after treatment was determined, she says.

In the case of a second opinion, the specialist also may give an interpretation to the treating physician over the phone or fax and include a written report later, Moore adds.