ED Coding and Reimbursement Alert

In the December 1999 issue of ED Coding Alert (page 89-91), we detailed correct coding and documentation for use of the code 93010 (electrocardiogram, routine ECG with at least 12 leads; interpretation and report only).

In the last section of the article, we touched on whether coders should report a code for a rhythm strip interpretation (93042, rhythm ECG, one to three leads; interpretation and report only) if the physician did not completely document the interpretation of a 12-lead ECG.

This is a controversial area, as many physicians and coders believe this is a valid practice, while others feel that it is fraudulent to report a rhythm strip interpretation, if a full 12-lead interpretation were actually performed.

We consulted two emergency physicians on the differences between a rhythm ECG and 12-lead ECG and whether it is permissible to report 93042 when a full ECG is performed.

Medicare Prohibits Reporting
Both 93010 and 93042 on One ECG

Other than lack of documentation, the real problem with the rhythm strip vs. full interpretation dilemma is that emergency department (ED) physicians often report 93042 when they know that the cardiologist who is doing the overread will report CPT 93010 , says Daryl LaRusso, MD, FACEP, an emergency physician in West Virginia.

Medicare has said that they dont want to pay for two interpretations of the same test, he adds. So, if the cardiologist is reporting 93010, the ED doctor cannot report another code to get paid for your interpretation.

Some physicians and coders believe this to be a valid way to report the service, since most ED physicians rely on the rhythm strip portion of the full ECG when making the diagnosis, says John Turner, MD, FACEP, medical director for coding and documentation at TeamHealth, Inc., an emergency physician staffing company based in Knoxville, Tenn.

When you do an ECG, it has 12 leads, but down at the bottom it has three rhythm strip leads, so when I am looking for the rhythm that the patient is in, I dont look at the 12-lead portion. The little individual strip isnt long enough to tell me what the rhythm is, you have to look down at the bottom at the rhythm strip, he explains. But, Medicare has said that it doesnt want to pay for the same piece of paper (the interpretation and report) twice. Therefore, it is necessary to find out whether the hospital or cardiologist is also billing for an interpretation of the same ECG.

For Medicare payers, if you are the only one billing an interpretation from a single ECG, the physician should use 93010 if he or she performed a full interpretation and report of a 12-lead ECG, including a separate report detailing comments on the rate, rhythm, axis interval, the QRS-T wave comments, any acute or chronic changes, comparison with the most recent tracing, and the clinical findings or diagnosis.

If the documentation of the interpretation only includes enough information to code an interpretation of the rhythm strip, then code 93042 should be used. The difference between a rhythm strip and ECG is only a couple of dollars, adds Turner. Instead of paying $28 for a 12-lead interpretation, you are going to get $21 for a rhythm strip. It is not an exponential increase in value for it.

Rhythm Strip Still Requires Separate Report

It is not appropriate to use 93042 by default just because there is not sufficient documentation of a 12-lead interpretation, says Turner.

The physician should include documentation of the interpretation of the rhythm strip in the patients chart too. Medicares requirement for documentation requires more than just the statement negative or within normal limits, Turner adds. You have to say something about the rate and the rhythm, or no ischemic changes or occasional PVCs or something.

Although the report may not be as detailed as that required for a 12-lead, it still requires documentation of the specific observations of the physician. Medicare wants to see a report for both (93010 or 93042), he adds. I usually say something like, rate is 78, slightly irregular, sinus arrhythmia. Or, I will say the rate is 78, rhythm is regular, with no ischemic changes or some minor, nonspecific ST changes noted. That is pretty much sufficient.

If there is only a cursory statement such as negative or ECG normal the coder can only consider the ECG interpretation as part of the medical decision-making under amount and/or level of data considered, when assigning the appropriate E/M code for the overall visit, Turner says. It would not be appropriate to bill the interpretation separately.