Reimbursement is dependent on the payer’s policy, any preexisting contractual agreements between the physician and payer, and the level of documentation provided by the physician. CPT coding principles clearly state that ECG interpretation is a separate and identifiable service.
Medicare will reimburse for ECG interpretative services, but only for a single physician interpretation for each medically necessary ECG. If a carrier receives more than one claim for a single eligible ECG, it is supposed to pay for the interpretation and report that directly contributes to the diagnosis and treatment of the patient. Such reimbursement should be for the interpretation on which the treatment was based or "contemporaneous" to the care given. Typically, Medicare pays the first bill it receives for a patient.
Medicare distinguishes between simply reviewing an ECG and providing an "interpretation and report." (see FAQ 2)
Medicare does not require that the ECG interpretation be recorded on a separate piece of paper; rather a complete written interpretation can be recorded within the emergency department treatment record. However, some Medicare carriers have independently established more restrictive criteria.
An interpretation and report are different than a review. CPT does not clearly state a documentation standard. CPT does state that there must be a “separate, signed, written and retrievable report”. Some ED Groups do this by creating an area within the chart for ECG interpretation.
Medicare states that the report must be a complete written report similar to that usually prepared by a specialist in the field and should be consistent with the service furnished. Medicare policy also states an "interpretation and report" should address the findings, relevant clinical issues, and comparative data when available. "ECG normal" is deemed an insufficient interpretation and report. Individual carriers may develop their own standards. You should review the local coverage determinations for your carrier on a regular basis. Elements in the ECG interpretation and report may include any of the following: rhythm, rate. axis, intervals (eg, PR, QRS, QTc), segment findings (Q-wave, ST elevation, ST depression, T wave abnormalities), and comparison to priors when applicable.
"Rhythm ECG, one to 3-leads; interpretation and report only" is a CPT-defined service (CPT 93042). The potential for reimbursement for such service will depend upon the appropriateness of the service, the quality of documentation, the respective payer’s policies, and whether the physician must comply with the payer’s policies.
According to CPT coding principles, a physician should select "the procedure or service that accurately identifies the service performed." CPT 93010 is defined as an "Electrocardiogram, routine ECG with at least 12-leads; interpretation and report only." If it is generally accepted that a complete CPT 93010 encompasses an interpretation and report of rhythm, then it would be inappropriate for a single physician to code for both 93010 and 93042 based upon a single 12-lead ECG tracing. However, if for a particular patient encounter both 12-lead ECGs and rhythm ECGs were medically necessary, performed, and interpreted by a physician, then CPT principles would allow the physician to code all the appropriate services.
If you bill for a rhythm ECG, the interpretation should be part of the patient record separate from the one contained on most ECG’s. It is not appropriate to use the rhythm ECG codes for reviewing telemetry monitors.
A basic CPT principle is that "any procedure or service...can be rendered by any qualified physician." CPT addresses how a single physician (i.e., the same physician or a physician of the same specialty working for the same medical group) can code for services provided for a patient encounter. CPT does not expressly address how different physicians can code for services they respectively provide in a patient encounter. If CPT 93042 ("Rhythm ECG, one to three leads; interpretation and report only") accurately portrays the service that the emergency physician provided, then that is the service that should be coded.
Some payers have established payment policies that modify CPT's coding principles. If a physician is required to adhere to such policies due to statute, regulation, or contractual agreement, then the physician must so comply. If a physician must comply with a payer's policies, and knowingly and willfully acts to circumvent such policies, then the physician might incur legal liability. A significant issue will be whether or not the physician's actions were performed with the intent to circumvent the policy or for some other reasons.
According to CPT coding principles, a physician should select "the procedure or service that accurately identifies the service performed." CPT 93010 is defined as an "Electrocardiogram, routine ECG with at least 12-leads; interpretation and report only." CPT 93042 is defined as "Rhythm ECG, one to three leads; interpretation and report only." If a physician were to provide an interpretation and report insufficient to substantiate a 93010, it would be inaccurate to code for 93010. In this case, the accurate service would be 93042, as long as the service was appropriately performed and documented.
Effective January 1, 2008, both the "at least 12-leads" and Rhythm (one to three leads) ECG services should:
In addition, Rhythm ECG services are appropriate when:
If a physician is required to adhere to a payer's policies due to statute, regulation, or contractual agreement, then the physician must so comply. In the absence of such guidelines, documentation should be of sufficient content and format to easily substantiate performance of the interpretation.
CPT states that "The physician interpretation of the results of diagnostic tests/studies (i.e., professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code with modifier -26 ."
However, a physician might consider whether it can be more efficient and beneficial to document all radiology interpretations consistent with CMS's criteria.
An emergency physician may bill for the interpretation and report of an X-ray for a Medicare patient when a "complete written report similar to that prepared by a specialist in the field" is documented. CMS has not identified a specific documentation standard but states that the physician must include relevant clinical issues, comparative data, and study findings. To these three categories, the American College of Radiology Standard for Communication, Diagnostic Radiology has suggested the addition of a description of the procedure and materials, any limitations, and clinical impression, conclusion, or diagnosis. CMS has not expressly adopted these specific suggestions.
CMS is on record as saying that the report CPT requires need not be on a separate sheet of paper. However, some Medicare contractors have independently established more restrictive criteria. Electronic records might facilitate creation of a separate timed and date interpretation and report for each diagnostic study. You should review the local coverage determinations for your carrier on a regular basis.
For more detail, see the Medicare Claims Processing Manual Chapter 13
A basic CPT principle is that "any procedure or service...can be rendered by any qualified physician." CPT addresses how a single physician (i.e., the same physician or a physician of the same specialty working for the same medical group) can code for services provided in a patient encounter. CPT does not expressly address how different physicians can code for services they respectively provide for a patient encounter. Under CPT, if a physician appropriately provides a service to a patient, the physician may code for it.
Payers, however, may establish payment policies that modify CPT principles. For example, Medicare rarely permits payment to both physicians. This will only occur when the knowledge and expertise of the second physician is presumed to be above and beyond that of the first, and if the second physician contributes substantially to the X-ray interpretation. The expertise of the second physician must also be medically necessary. Some carriers require that a -77 modifier (Repeat Procedure by Another Physician) be used when both physicians bill. Of course, this requires that the respective physicians somehow know that the other is submitting a claim. Typically, Medicare pays the first bill it receives for a patient.
On a basic level--there is the potential for 3 "points" in the CMS-suggested Medical Decision Making (MDM) audit scoring in the area of Amount And/ Or Complexity of Data to Be Reviewed for radiology/cardiology/lab and other diagnostic services. One point is assigned for ordering the study and using the results for patient evaluation/management. Two points are available for the direct visualization of the tracing/film/specimen.
It is possible to give credit for the single point assigned for ordering of the study in addition to billing for the interpretation of the test. It is the latter 2 points that raise some question and are discussed in this scenario. This scoring system is derived from a CMS-suggested audit scoring sheet widely distributed nationwide.
The discussion revolves around the fine point of whether the complexity of data to be reviewed is an assessment of service separate from the work of the interpretation of the test. If these are separate, then the 2 points can be given in addition to billing for the interpretation of the test. CPT addresses this issue by noting that the interpretation of diagnostic tests is not included in the levels of E&M services. On the other hand, Medicare seems to differentiate between a "report" and a "review" in respect of billing and getting credit under the complexity of data section of the MDM. In that there is no specific clarification on this issue and payment policies do differ, you are advised to contact your local carrier for advice.
[Look for changes to this in 2023]
Diagnostic studies have two components that may be separately compensated: the professional interpretation component and the technical component, which reimburses for the necessary supplies, materials, and staff. Medicare generally will only pay for studies that are preformed to diagnose and manage acute problems. To determine which studies meet the specified criteria, carriers employ ICD-9 10 screens to review claims for "medical necessity." Unless the claim contains an ICD-9 10 diagnosis that is acceptable to the carrier, it may be rejected on the initial pass. However, the appeal process is often available for review of such initial claim rejections.
CMS has renamed Local Carrier Medical Policy to Coverage Documents. They are either classified as National Coverage Documents (NCD) or Local Coverage Documents (LCD). Most if not all Medicare Intermediaries have web sites, which contain their Local Coverage Documents. You may also use the search function available from CMS to find National Coverage Documents (NCD) and Local Coverage Documents (LCD). LCD’s can and do differ from NCD’s.
This search function is available at http://www.cms.gov/mcd/search.asp
CPT coding principles allow any qualified physician, who provides a service to a patient, to code for the service. CPT does not address the effect of more than one physician performing a service for a patient. However, some payers have adopted payment policies regarding the latter situation. If a physician is required to adhere to such policies because of statute, regulation, or contractual agreement, then the physician must comply.
For example, Medicare published its final rule on this subject in the December 8, 1995 edition of the Federal Register. Vol. 60, NO. 236., X-rays and Electrocardiograms Taken in the Emergency Room. Medicare intends to pay for only ONE X-ray and/or EKG interpretation and report for a single diagnostic. However, there is a provision for payment of a second interpretation for the same diagnostic under unusual circumstances, such as a questionable finding for which the physician performing the initial interpretation believes another physician’s expertise is needed.
CMS encourages hospitals to work with their medical staffs to establish guidelines for the billing of X-ray and EKG interpretations for emergency department patients, and thereby ensure that only one respective interpretation and report per single diagnostic is routinely billed. If a Medicare carrier receives only one claim for an interpretation and report of a diagnostic, and the procedure is reasonable and necessary, the carrier will pay the claim presuming that the one service billed was a service to the individual beneficiary and not a quality control measure.
If a Medicare carrier receives multiple bills for the same interpretation and report for a single diagnostic, the carrier is to pay for the interpretation and report that directly contributed to the patient's diagnosis and treatment. A radiologist's respective interpretation and report could meet this requirement if a written or oral (then subsequently written) interpretation and report was conveyed to the treating physician before the end of the patient encounter.
The politics or policy of your facility or contractual arrangements may dictate who bills for these studies.
The 12/8/1995 Medicare Final Rule content can be found on the ACEP website at:
CPT states that two specific chest X-ray interpretations (CPT codes 71010 chest single view frontal and 71020 chest two views frontal and lateral) and "information stored in computers (e.g., ECGs, blood pressures, hematologic data (CPT code 99090)" are considered "bundled" into critical care and as such may not be coded separately. Under CPT coding principles, interpretations of X-rays other than CPT 71010 and 71020 can be coded in addition to Critical Care Services. Also, because the Critical Care reference to ECGs is specific to CPT 99090, the services associated with 12-lead ECGs (CPT 93000 routine ECG with 12-leads, with interpretation and report, 93005 12-lead only without interpretation and report, 93010 interpretation and report only) and Rhythm ECGs (CPT 93040 rhythm ECG one to three leads, with interpretation and report 93041 tracing only without interpretation and report, 93042 interpretation and report only) can be coded in addition to Critical Care Services.
Some payers have adopted payment policies, regarding the coding of separate procedures and Critical Care Services that differ from CPT. If a physician is required to adhere to such policies because of statute regulation, or contractual agreement, and then the physician must so comply.
For example, CMS's "Correct Coding Initiative" (CCI) adds another restriction on the ability to code for ECG interpretation and Critical Care Services provided to a Medicare patient. CCI does not allow the combined use of Critical Care Services and Rhythm ECG (CPT codes 93040, 93041, 93042).
ACEP has prepared a packet of material on this issue, which is available to members. This is an excellent source of information for members to use for such discussions. The key points the packet table of contents may be found on the ACEP web site in the reimbursement section at https://www.acep.org/administration/reimbursement/diagnostic-interpretations/acep-information-packet/. For additional information, contact us via e-mail at firstname.lastname@example.org
ACEP has prepared a packet of material on this issue, which is available to members. This is an excellent source of information for members to use for such discussions. The key points the packet table of contents may be found on the ACEP web site in the reimbursement section at https://www.acep.org/administration/reimbursement/diagnostic-interpretations/acep-information-packet/. For additional information, contact us via e-mail at email@example.com.
Updated December 2021
The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only. The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.
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For information about this FAQ/Pearl, or to provide feedback, please contact David A. McKenzie, ACEP Reimbursement Director at (469) 499-0133 or firstname.lastname@example.org.