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ED Coding and Reimbursement Alert

Zero In on EKG Payment:

Reports,Strips and Critical Care

Published on Sun Jun 01, 2003

Fight for electrocardiogram (EKG) interpretation payment in the ED otherwise, Medicare will send reimbursement for your ED physicians to cardiologists.

Don't give Medicare any reason to doubt the medical necessity of this service. When you report 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only), make sure your physician's documentation supports a contemporaneous interpretation one that is a timely and direct contribution to patient diagnosis and treatment.

In addition, ensure the interpretation is a complete, written report, similar to that prepared by a specialist, says Robert Kottman, MD, at Alamo Physicians Services Inc. in Universal City, Texas. Only a "report" of this kind will support a separate interpretation code. If the ED physician merely reviews a particular tracing or film after another physician has interpreted it, you should include this work in the E/M code, he says.

The way to improve documentation for EKG payment is to nail down the details of cardiology reports. You should also master your coding for rhythm strips and critical care. Your EKG claims could meet resistance from payers, especially if cardiologists are charging over-read services for the same EKG, but perfecting these details will help you defend your claims. (To read more on basic and general information on this topic, refer to "Be the First to the Finish Line With EKG and X-Ray Interpretation" and other related articles in the December 2002 ED Coding Alert.)

Get Familiar With Specialty Reports

What do references to p waves and QRS complexes in the physician's notes mean? If you're not sure, you should brush up on cardiology terminology that will help you identify complete EKG reports required when you submit EKG interpretation codes for ED physicians.

A complete cardiology report should include rhythm and rate, axis, intervals, p waves, the QRS complexes and ST segments, and T waves, Kottman says. In case you're unfamiliar with these terms, he provides four helpful definitions:

  • Pwave: a record of the movement of electrical activity through the upper heart chambers and recorded when they contract

  • QRS complex: a record of the movement of electrical impulses through the lower heart chambers and recorded when they contract
  • ST segment: appears as a straight, level line between the QRS complex and the T wave. Elevated or lowered ST segments may mean the heart muscle is damaged or not receiving enough blood

  • T wave: corresponds to the period when the lower heart chambers are relaxing and preparing for their next muscle contraction.

    Because your physicians need reports similar to a specialist's to secure payment for their interpretations in the ED, let them know what a complete cardiology report entails and provide an example of a thorough statement. Kottman offers this example: "Normal sinus rhythm with a rate of 84. Adownward coding of the PR interval and ST segment is elevated in all leads; this is consistent with acute pericarditis."

    Don't worry about submitting the report on a separate piece of paper. Medicare doesn't require it, says Carol L. Edelberg, CPC, CCS-P, president of Medical Management Resources, an emergency medicine coding company based in Jacksonville, Fla.

    93042 Must Be Separate From 93010

    Not surprisingly, experts don't always agree about when to report three-lead EKGs (93042, Rhythm ECG, one to three leads; interpretation and report only).

    According to Edelberg, who advocates a more lenient use of 93042, "If CPT 93042 accurately portrays the service that the emergency physician provided, then that is the service that should be coded." But that doesn't mean  you should report 93042 with a 12-lead EKG (93010) in all cases. Here are two scenarios involving the appropriate professional codes and how to report them:

    Scenario #1: The ED physician interprets a three-lead rhythm strip for the same patient for which a cardiologist later interprets a 12-lead EKG.

  • Do not report 93042 if the ED physician uses the same tracing used for a 12-lead EKG billed by a cardiologist. Doing so "is clearly not proper," argues Bart Hershfield, MD, FACEP, president of CHECKCHART Template Documentation System.

    Identification of the cardiac rhythm is one of the elements of a 12-lead EKG, and most 12-lead EKG machines provide a rhythm strip to help facilitate this element of the 12-lead interpretation, he says. This reporting mistake is "not an uncommon error in emergency medicine coding," he says.
  • You can report 93042 when a cardiologist reports a 12-lead EKG interpretation if you can provide the medical necessity for performing a rhythm strip in addition to the original EKG, Hershfield says.

    Your physician usually orders an additional, and separate, three-lead EKG because the patient's rhythm changed, a medically necessary reason. You must have documentation of the rhythm strip order and of the rhythm strip's tracing provided on a chart, Hershfield says. The rhythm strip should last at least six to 10 seconds, a number that varies depending on the payer, he says. You should also have a written interpretation of the rhythm strip, he adds.

    Check with your payers regarding what documentation justifies a 93042 report, Edelberg says.

    Scenario #2: The ED physician interprets both the three- and 12-lead EKGs. Again, medical necessity determines whether you'll be paid for both, Kottman says. Carriers may suspect that your physician is looking at 12-lead EKGs and rhythm strips at the bottom of them to get paid twice, he warns. You have to submit a separately maintained rhythm strip interpretation and a separate strip that's longer than what is at the bottom of the 12-lead EKG to get paid for both, he says.

    Critical Care Doesn't Cripple EKG Payment

    Some clear and simple EKG advice: You can report EKGs in addition to the critical care codes, 99291 and 99292, Hershfield says.

    Don't be confused by the fact that critical care codes bundle in 99090 (Analysis of clinical data stored in computers [e.g., ECGs, blood pressures, hematologic data]). Because the critical care reference is only to 99090, you can separately report 12-lead EKGs codes, Edelberg says. You can also separately report rhythm EKGs, she adds.

    Remember to add modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99291-99292 when you report additional procedures to critical care, Hershfield says.

     

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