Part B Insider (Multispecialty) Coding Alert

Cardiologists and emergency physicians tussle over payments

A patient comes into the emergency room, and the emergency physician orders a routine electrocardiogram and then interprets it. Some time later, the hospital cardiologist also looks over that EKG and tries to bill for the interpretation.

The problem is, Medicare and many other payers will only cover one interpretation of a routine EKG. "That's kind of a long-time issue with emergency physicians," says Laura Siniscalchi, a senior consultant with Deloitte & Touche in Dover, Mass. "They're usually providing the immediate service to the patient, but usually it's over-read by the cardiologist in the hospital."

Medicare clearly wants to pay only the physician who's actually using the EKG to make a diagnosis for the patient, Siniscalchi says. But that can be either physician, depending on their circumstances. But typically, Medicare will pay for the first interpretation and consider the second a "quality-control measure," she adds.

Not surprisingly, David McKenzie, director of reimbursement with the American College of Emergency Physicians, feels that the emergency doctor should be the one to receive payment for the interpretation, unless the cardiologist is interpreting it contemporaneously. Cardiologists are "not providing a service to the beneficiary - they're providing a quality-assurance service to the hospital."

This has been a bone of contention for years, not only with cardiologists but also with radiologists who perform second interpretations of x-rays, says Steve Verno, director of reimbursement for Emergency Medicine Specialists in Hollywood, Fla. Cardiologists and radiologists ought to be on call 24 hours a day to interpret EKGs and x-rays if they want to get paid separately for the interpretation, Verno says.

"I've seen hospitals get up an agreement" governing emergency doctors and cardiologists, Siniscalchi adds. "If it's done in the ER, the cardiologists bill for it ... but they pay something back to the emergency physicians." If this is a point of contention for your physician, suggest that he talk to the hospital about coming up with a policy for sharing the reimbursement.

Medicare will only pay for more than one interpretation of a diagnostic test such as an EKG or an x-ray in "special circumstances," for example if there's something questionable that requires another physician's interpretation, Siniscalchi says. This could also happen if the first physician has a "controversial finding" that requires an expert opinion from a second physician.