ED Medical Coding and Billing: Coding Strategies for Diagnostic Studies


Let us focus on EKG interpretations and basically diagnostic interpretations in general. We do know that the interpretation of any diagnostic tests or study performed in the conjunction with the patient visit should be reported in addition to the appropriate E/M service. Read this expert medical billing and coding training article for more.

Now, there are a number of things that emergency physicians do interpret. And that varies between state and between region and what groups are billing for what. But I let us go through specifically about the more common ones that are being billed.

The Interpretation of x-ray or EKG does not does contribute to the diagnosis or treatment of the emergency patient that is not deemed to be medically necessary and not reimbursable.

Our expert in a medical coding conference cited this example. We do an interpretation of an EKG out of the 100% necessary for that particular case. We are ordering on EKG and looking for some subtle changes on that that may indicate to the person as having some underlying coronary or artery disease that could be a rhythm problem with the heart itself. But definitely we are ordering that for again reasons based on our evaluation or evaluations about the historical and on following the exam.

So some of it comes in complaining of things such as obviously chest pains, for pretty obvious reasons for getting a cardiogram but someone could be complaining of profound. You know, this and this could have had a single episode, could have had, you know, complain of global weakness. But there are a number of reasons why you order an EKG including abdominal pain by the way.

Aug 14, 2018
Kim Garner-Huey
Aug 30, 2018
Jill M. Young
Sep 11, 2018
Terry A. Fletcher
Sep 11, 2018
Jill M. Young

So once you do that, you know, and going through your medical coding training, et cetera, you'll understand the certain things coronary wise could present multiple different presenting complaints. So once again, you know, order an EKG, interpretation an EKG is done by the emergency physician 100% of the time. It's very rare that another physician interprets it for the emergency physician. So that would be important.

So when we talk about medical necessity when we are looking at EKGs or looking at x-rays, you're ordering them specifically because it's going to aid in your diagnosis. Now, an interpretation performed by a cardiologist or radiologist contemporaneous obviously would supersede or were together with the emergency physician. But very uncommonly do you have a cardiologist contemporaneously review that cardiogram.

Most times EKG is reviewed after the patients – frankly after the patient is gone whereas a radiologist had different story because between the hours of 7:00 – 7:00 to 8 o'clock in the morning until around 5 o'clock in the afternoon, you might very well get a reading of an x-ray that would be done by a radiology whereas after 6:00 pm or on weekends, it's uncommon to get a contemporaneous reading of your x-rays. So we'll kind of leave it at that so you have an idea of, you know, what the timing is.

EKG is usually 100% across the board. The emergency physician is doing the initial interpretation. And it is contemporaneous with the patient here. Very rarely does a cardiologist provide that reading at the time of patient care or contemporaneous with the patient visit whereas radiology, that can occur usually doing daytime hours, can occur certainly in the evening but only when that particular physician has been asked to look at that. Routinely that would not be done.

You know, interpretation is provided days or hours after the patient is sent home, really doesn’t meet the requirements for contemporaneous reading. Any interpretation that's not performed contemporaneous is not medically necessary. It's interesting because that's a debatable point because obviously in the practice of emergency medicine, you know, we will be interpreting a cardiogram. But there are certain requirements that the hospital provides the overread of that EKG.

Is it required across the board? Well, sometimes for different certifications, et cetera for a hospital. You know, you'd want to have – you know, your EKGs overread. X-rays certainly you'd want to have overread, you know, by the radiologist. So whether it's medically necessary may not be medically necessary at the time of visit but certainly for oversight of the interpretations that, you know, that may very well be necessary.

When we're talking about EKG and x-ray interpretations, there's a lot of political influence here. There are, you know, because of the way the mandates or regulations or medical coding guidelines were written many years ago, related EKG interpretations, the hospital has an interesting role in here where they help decide who primarily bills for EKG interpretations and also provides for, you know, the initial reading of x-rays themselves.

And there are many times that the cardiologist will bill for this in the 93010 primarily versus the emergency physician who's reading and contemporaneous. This is not, you know, 50% across the board, 60%, 70%. It really does vary. The majority of emergency physicians do bill for the 93010 primarily whereas in some locations, cardiologists do bill for it primarily. So I don’t want to be, you know, naïve saying it's one way versus another. But it's probably about 80% of the time it is billed primarily by the emergency physician.

X-ray interpretations are much different approach. Probably anywhere between 10% and 20%, probably 10% of x-rays are billed primarily by the emergency physicians as the initial interpretation whereas approximately 90% are really billed primarily by the radiologist. So just to give you an idea and a background related to that.

Medicare generally does pay for the first claim that’s submitted whether it's from the (emergency) physician, cardiologist or a radiologist. So they really don’t look – they're obviously part of the submission of a claim does not include whether this was contemporaneous with the patient care or not. So they basically do pay for the claim that the first claim submitted. That's probably a very high percentage of cases.

Let's say you have two claims for the same EKG. They will go ahead and pay for the first one that it's received. Very uncommonly I would say will they determine which one led to the diagnosis and treatment of the patient because they frankly don’t know that. And of course remember the majority of claims that are submitted and certainly that's their goal are done electronically. And they're in electronic transmission. There's nothing within that transmission which designates whether you or are the one that interpreted that contemporaneous with the patient care. So it would be difficult from Medicare’s perspective to know which one.

Now, having said that, it doesn’t mean they can't request a, you know, hard copy of the report to hard copy of the treatment record to determine which one was contemporaneous. That certainly can happen but it is not that frequent

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