ED Coding and Reimbursement Alert

Question: We are not getting paid for 93010 or 93042. Is it because we are billing them with critical care codes (99291-99292)?

Ohio Subscriber

Answer: Many ED coders have run into problems when billing for 93010 (electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) or 93042 (rhythm ECG, one to three leads; interpretation and report only).

HCFA has requirements for billing electrocardiograms (ECGs) performed in the ED. The agency says only one interpretation of an ECG will be paid for an ED patient. HCFA advises hospitals that if they allow a physician to perform and bill for a medically necessary service [the interpretation and report] in an ED and another physician performs and bills for the same service, the Medicare carrier will pay for the service that determined the diagnosis. For most ED patients, this is the emergency physician.

Note: These requirements can be found in the Dec. 8, 1995, Federal Register and were published as part of the bulletin Medicare Program, Revisions to Payment Policies and Adjustments to the Relative Value Units under the Physician Fee Schedule for Calendar Year 1996.

However, HCFA says, there is a provision for payment of second interpretation under unusual circumstances such as a questionable finding for which the physician performing the initial interpretation believes another physicians expertise is needed.

Complete documentation is necessary when billing for the interpretation of an ECG. If a patient presents to the ED with chest pain, and a cardiac problem is suspected, the ED physician will likely order an ECG and then interpret the results to see if the problem is in fact cardiac-related.

There may be practical or political complications if, in your facility, ED cardiograms are later read by the local cardiologist. Medicare has said that it doesnt want to pay for two interpretations of the same test. Therefore, if the cardiologist is reporting 93010, the ED doctor cannot report 93042 to get paid for your interpretation. Also, it is not appropriate to use 93042 by default just because there is not sufficient documentation of a 12-lead interpretation (93010). The physician should include documentation of the interpretation of the rhythm strip in the patients chart too.

For more information about correctly coding for ECGs, please see Written Report Reduces Denials of Rhythm Strip Interpretation in the January 2000 ED Coding Alert, page 6, and Correct Payment for ECG Interpretations Requires Accurate Documentation, Code Assignment in the December 1999 ED Coding Alert, page 89.

Some questions have been raised about whether you can bill 93042 in addition to 99291 (critical care). Codes 93010 and 93042 were bundled with critical care, but that is no longer true.

An example of when 93042 would be used with critical care is highlighted in Case Study: Receive Optimum Payment for Critical Care in the October 2000 ED Coding Alert, page 77.