ED Coding and Reimbursement Alert

Specificity and razor-sharp record keeping hold the key

Emergency department physicians perform diagnostic electrocardiography (ECG) tests every day, but whether you earn reimbursement for them depends on establishing credible medical necessity - and that means choosing the correct diagnosis code.
 
You can describe these services with one of three codes: 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report), 93005 (... tracing only, without interpretation and report), and 93010 (... interpretation and report only). Since the ED physicians don't own the equipment they're using, you'll report 93010 most often.
 
During the noninvasive procedure, the physician places electrodes on the patient's chest, arms and legs to produce an electrical recording of the heart. Technically speaking, the ECG is a graphic tracing of the electrical activity caused by the impulses that travel through the heart that determine the heart's rate and rhythm as detected at the body surface.
 
In order to show medical necessity for the ECG, you need to choose an ICD-9 code that tells the payer exactly why the ED physician needed to perform the service. Increasingly, carriers are denying payment if the ICD-9 codes are not specific enough. The physician's diagnosis must justify the interpretive test, such as an ECG, says Tamra McLain, CPC, coding manager for HRA Medical Management Inc. in the San Diego area.
 
Ensure you're coding to the highest possible level of specificity by following this airtight coding and assessment process:
 
1. Gather complete information. When you are translating the physician's documentation into codes, you need complete information - and you may not have enough to code the services based on her written notes.
 
For example, if the doctor writes "heart failure" in the patient's record, you should ask for more details. Heart failure (428.x) is an incomplete (truncated) code, and if you don't carry it out to the highest degree of specificity, your carrier is likely to deny the claim. You need the data that will help you determine the type of heart failure.
 
Congestive heart failure, unspecified (428.0), for example, is a more specific code that will allow the carrier to pay you for the ECG. Keep in mind that a rule-out diagnosis may be clinically important to have in the chart, but it will not justify the procedure or service from the insurer's perspective, and you shouldn't code it directly. In such a case, you'll have to seek out more information on the specific symptoms from the patient's chart or by asking the physician.
 
And, due to the nature of the clinical interaction in the ED, carriers accept symptom-based diagnosis codes. Codes such as unspecified chest pain (786.50) or shortness of breath (786.05) may be all the clinical information available during the physician's initial treatment.
 
Ideally, diagnosis information should come from a clear, concise and specific diagnosis written in the patient's chart - but in reality, you won't always be immediately privy to this kind of detail.
 
2. Use the code with the highest specificity. No matter how well the ED physician communicates the patient data, you must ensure that you use the right code and that you're carrying it to the highest digit possible.    

This process involves not only noting any caution or warning symbols in the ICD-9 manual (some color-coded books use yellow for nonspecific codes and red for those with missing digits) but also having a working knowledge of the terminology for electrocardiograms. If the physician sees a patient for heart failure, you will have to support the diagnosis codes by gathering enough information to know whether, for example, the patient has congestive heart failure, unspecified (428.0) or left heart failure (428.1)
 
Remember to follow this simple rule: Assign three-digit codes only if there are no four-digit codes within that code category, assign four-digit codes only if there are no fifth-digit subclassifications for that category, and assign the fifth-digit subclassification code for those categories where it exists.
 
In this example, the specific code to report is 428.0 (Congestive heart failure, unspecified). An example of fifth-digit specificity is found in the group of codes describing symptoms involving the respiratory system and other chest symptoms (786). In the ICD-9 manual, there is a "Check 5th digit" symbol in front of 786.0, so you know you need greater specificity. The fourth and fifth digits delineate further symptoms of respiratory disorder such as hyperventilation (786.01), orthopnea (786.02), apnea (786.03), Cheyne-Stokes respiration (786.04), shortness of breath (786.05), tachypnea (786.06) and wheezing (786.07). 
 
3. Run frequent reports. You'll be able to see tangible evidence of solid diagnosis coding if you evaluate regular code reports. About every two months, use your billing software to generate a report of the top 50 diagnosis codes and top 50 CPT codes each physician used.
 
Carefully review the reports, noting which nonspecific codes the physicians used and how often. Report this information to the doctors and keep track of each report to benchmark progress and trends.
 
And consider reviewing all denials monthly to see if an incorrect ICD 9 code (one that doesn't meet the requirements for medical necessity) is the culprit. Updating your encounter forms at least annually is always beneficial, says Lisa M. Clifford, CPC, owner of the multispecialty coding firm Clifford Medical Billing Specialists Inc. in Naples, Fla. The ED should check its encounter forms and charge slips to make sure they don't contain outdated or deleted codes for either CPT or ICD-9. Keep in mind that ED physicians are frequently unaware of the many ICD-9 codes available to them. "Especially since there's a wide range of diagnosis codes for ECGs, you want to make sure you're using the most specific and valid code," Clifford says.
 
Doctors see only the small sample presented to them on their encounter form, and many limit their selection to these codes. "You should be sure to evaluate all applicable diagnosis codes for possible inclusion on the encounter form to give the doctor the full range of options," Clifford says.