ED Coding Update

The controversy over billing for EKG/rhythm strip interpretations in the ED

[This quarterly column is written by Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates, Baton Rouge, LA.]

Increasing payer scrutiny over diagnostic interpretations and continued belt-tightening at the private payer level has resulted in a resurfacing of the EKG interpretation payment issue for emergency physicians. There is no doubt that the interpretation of diagnostic tests for ED patients is an invaluable service. However, payer audit departments seem to be increasing their scrutiny of many ED-based diagnostic interpretations, and are attempting to bundle this service into the E/M level or deny the services outright.

Thus, two very separate issues remain. The first, do Medicare and private payers pay for EKG interpretations in the ED? The answer is "yes" for Medicare and varies from one private payer to the next. The second and an increasingly troublesome issue is, once paid, does the documentation in the record appropriately provide the rationale for the test as well as evidence that a formal interpretation was provided when the record is audited? If you are getting paid for this valuable service you may still want to review the rules governing interpretations to assure you won't lose your audit appeal if audited.

The two most frequently billed EKG interpretations in the ED are:

  • 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only); and
  • 93042 (Rhythm ECG 1-3 leads; interpretation and report only).

Some requirements to bill for the interpretation of these services include:

  • There must be a specific order;
  • Following the order, there must be a separate, signed, written and retrievable report;
  • Documentation should provide the rationale to support the need for the service as well as the detailed interpretation report, which does not need to be on a separate record but must be a separate entry in the ED record.

93010 EKG Interpretation

Medicare rules have been clarified over the past years, and private payers have their own policies for payment of EKG interpretations. Per Medicare clarifications, the interpretation and report should address current findings, relevant clinical issues, and comparative data when available. Recent carrier audit activity indicates Medicare auditors are looking closely at the comparative data issue and denying payment when it is not documented, so it's a good idea to provide comparative data when it is available and clearly reference when it is not, as part of the formal interpretation.

Medicare will pay for the interpretation that contributes to the diagnosis — the contemporaneous reading in the ED rather than an over-read after the patient has left the ED.

Medicare differentiates between a review and a formal interpretation, so documentation of the interpretation that is billed separately from the evaluation and management service must clearly support that the ED provider is writing the official interpretative report which should address the pertinent elements of the following:

  • Rhythm
  • Rate
  • Axis
  • Intervals
  • ST segment change
  • Comparison to a prior EKG
  • Summary of clinical condition and findings.

Although Medicare has not officially clarified how many of these elements must be addressed in a formal interpretation, industry standards for the ED seems to require at least three.

A review is not a separately billable service. The value of a review is included in an evaluation and is not separately billable. So, the documentation must specify the elements of an official interpretation in order to be a separately billable service.

93042 Rhythm Strip

This service is often billed inaccurately when the physician simply reviews the telemetry monitor strips generated by the monitoring system. In order to bill for a rhythm strip interpretation, there must be a diagnosis or triggering event documented in the medical record. Also, stay clear of ordering an EKG interpretation but bill for a rhythm strip if payers don't reimburse for EKG interpretation, but do bill for rhythm strip interpretations. You should bill for the service that most accurately describes the service you provide.

What about residents and teaching physicians?

If the resident prepares and signs an interpretation, the teaching physician (TP) must indicate that he or she personally reviewed the image and the resident's interpretation, and that he or she either agreed with or revised the findings. Medicare does not pay for an interpretation if the TP only countersigns the resident interpretation. To be payable to the TP, the TP must personally provide an identifiable and separate service. (CMS Transmittal 2303 September 14, 2011).

Internal reviews of your billed EKG and rhythm strip interpretations should be performed on a routine basis to assure you can defend your billing of these services if audited.