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: Physicians perform ECGs regularly, but payment for this intricate procedure depends on whether you can prove medical necessity.

Coders report ECG tests with these codes:

- 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) if the physician performed the ECG and the interpretation

- 93005 (... tracing only, without interpretation and report) if the physician performs an ECG with tracing only

- 93010 (... interpretation and report only) if the physician does not own the ECG equipment.

As for proving medical necessity for ECG exams, it begins with solid diagnosis coding. Choose an ICD-9 code that tells the payer exactly why the ED 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 three-digit code 428 (Heart failure) the claim will be denied.

Why? It is an incomplete code, and if you don't represent the type of heart failure with a fourth digit, a denial is likely.

You should observe these rules when performing diagnosis coding:

- Assign three-digit codes 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.

- Don't neglect reports. About every two months, use your billing software to generate a report of the top-50 diagnosis codes and top-50 CPT codes used by the doctors in your ED. Review the reports, noting which nonspecific codes the physicians used and how often. 

Many carriers have medical-necessity diagnoses lists for ECGs. For your major payers, such as Medicare, ask for the approved diagnoses list and educate your physicians about the diagnoses that support the tests they perform regularly.