ED Coding and Reimbursement Alert

Emergency department (ED) physicians often review and interpret rhythm strips on patients with cardiac symptoms. Nonetheless, claims for these legitimate services are often denied by Medicare and private payers because rhythm strips are a component of a more comprehensive 12-lead electrocardiogram (ECG or EKG), which is typically read by cardiologists. When both physicians attempt to receive reimbursement for services rendered to the same patient on the same date, the ED physician charges usually go unpaid. In fact, the Correct Coding Initiative (CCI) has implemented an edit prohibiting codes describing these services from being reported together during the care of a Medicare beneficiary.
 
When a patient with a suspected cardiopulmonary disorder is seen in the ED, the physician will usually order a 12-lead ECG. "Each lead provides a different view of the heart," explains Michelle Ashby, CRNP, of The Heart Group in Lancaster, Pa., which employs 12 nurse practitioners and 13 cardiologists. "Some of the leads provide information about the anterior wall of the heart, while others reflect the lateral and inferior walls, for example." The interpretation and report for a complete 12-lead ECG are reported with 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only).
 
Each lead collects about three seconds of information at a time representing only a couple of heartbeats, she adds. "At the bottom of the ECG, there is usually a longer section of one to three leads. This rhythm strip is used to determine the rhythm of the heart. The ED physician can tell if patients have normal sinus rhythm, for instance, or if they are suffering from a problem like atrial fibrillation [427.31]," Ashby says. Interpretation of a rhythm strip is described in 93042 (Rhythm ECG, one to three leads; interpretation and report only). Usually, the ED physician will use the information from the rhythm strip to help determine a diagnosis. Later, a cardiologist may review the details contained in the entire ECG strip.

Neither Service Is Considered 'Distinct'

"When you look at the issue logically, the rhythm strip interpretation is a distinct service, provided at a separate time by a different physician than the full interpretation of the 12-lead ECG," points out Mason Smith, MD, FACEP, CEO of Lynx Medical Systems, a facility and physician coding and billing service based in Bellevue, Wash. "You would think both physicians should be able to report the service. But payers don't see it this way. They see the full 12-lead interpretation as including the initial rhythm strip service. It is a controversial area that has been discussed at great length."
 
In some instances, Smith says, ED physicians attempt to use modifier -59 (Distinct procedural service) with 93042 when they know a second physician will be reporting 93010. "This approach hasn't been met with much luck, however. Payers usually will not reimburse for the rhythm strip even when a modifier is appended."
 
ED physicians are more successful at getting reimbursed when their tax identification number is different from the other reporting physician's, Smith adds. "If both report under the hospital's number, there is little likelihood that both services will be paid. But if the cardiologist's interpretation and report falls under the hospital's tax ID and the ED physician bills under his or her own number, there is a greater chance for reimbursement."

ED Physicians May Report 12-Lead ECG

He notes that there are also instances when ED physicians should simply provide the interpretation and report for the comprehensive 12-lead ECGs, billing 93010 without involving a cardiologist. "The output from some ECG equipment includes an interpretation of the data collected. The ED physician must review it closely, add relevant notes on the strip and sign it."
 
If the ED physician bills for the full ECG, documentation must support the interpretation, Ashby notes. The report must include comments on the heart rate, rhythm, axis interval, the QRS-T wave, any acute or chronic changes, comparison with the most recent tracing, and the clinical findings or diagnosis.
 
Similarly, the ED physician must document the interpretation of the rhythm strip in the chart as well, if that is the extent of the service provided. It is inappropriate to bill 93042 simply because documentation doesn't support a 93010 claim. Medicare and other insurers do not consider comments like "negative" or "within normal limits" adequate documentation for 93010. The ED physician must note specifics about the heart rate or rhythm, or include comments like "occasional PVCs" or similar findings.