ED Coding and Reimbursement Alert

Question: What codes should we use to report diagnostic electrocardiography (ECG) tests? And how can we prove medical necessity for these tests? We have gotten several recent "medically unnecessary" denials on ECG claims.

Minnesota Subscriber

Answer: Emergency physicians often order ECGs based on presenting symptoms to determine whether the patient has a cardiac problem. Payment for this diagnostic test often depends on whether you can prove medical necessity. Choose an ICD-9 code that tells the payer exactly why the emergency physician needed to perform the service. If your diagnosis code is not specific enough, payers may balk at accepting your claim.

Start by getting all the information you need from the doctor. If the notes do not provide you with enough information for an accurate ICD-9 code, you may have to ask for clarification. For example, if the doctor writes "heart failure" in the patient's record and you use only the 3 digit code 428 (Heart failure) the claim will be denied. Heart failure alone is an incomplete code; indicate the type of heart failure with a fourth digit to avoid denials

Additionally many carriers have medical necessity diagnosis lists for EKGs typically described as "coverage determinations." There are two types of coverage to administer benefits for beneficiaries: National Coverage Determination (NCD) Policy and a Local Coverage Determination (LCD) Policy.

• NCD- National Coverage Determination explains the coverage of services on a national level.
• LCD- Local Coverage Determinations are confirmed to a specific geographic area and usually a specific Medicare carrier or MAC. For your major payers, such as Medicare, visit their website and obtain the approved diagnosis list and educate your physicians about the diagnosis that support the tests being performed.