EKG Billing

Contents:

1. EKG background
   1. Costs of EKGs
2. EKG ICD-10 codes
   1. EKG coding tips
   2. Documentation
3. EKG billing services
4. EKG reimbursements

EKG Background

Why is an electrocardiogram (ECG or EKG) performed? An ECG gives two major kinds of information. First, by measuring time intervals on the ECG, a doctor can determine how long the electrical wave takes to pass through the heart. Finding out how long a wave takes to travel from one part of the heart to the next shows if the electrical activity is normal or slow, fast or irregular.

Second, by measuring the amount of electrical activity passing through the heart muscle, a cardiologist may be able to find out if parts of the heart are too large or are overworked.

Typical Costs of EKGs

There are typically two costs—the cost of the procedure itself, and the cost of the analysis of the readout. Patients with medical insurance that covers a portion of the cost of the EKG can expect to pay $30-$100 in copays for both the test and the analysis.

Uninsured patients can expect to pay $500-$3,000 total for an EKG. An EKG averages $1,500, according to NewChoiceHealth.com, but some locations charge as high as $2,850. Typically prices are higher for services in metropolitan areas, than in smaller rural communities.

Electrocardiogram (ECG or EKG) – CPT and ICD-10 Codes

Procedure code and description

• 93000 – Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report
• 93005 – Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report
• 93010 – Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only
• 93040 – Rhythm ECG, 1-3 leads; with interpretation and report
• 93041 – Rhythm ECG, 1-3 leads; tracing only without interpretation and report
• 93042 – Rhythm ECG, 1-3 leads; interpretation and report only

ICD-10-CM Diagnosis Codes
I10 Essential (primary)  hypertension

• R94.31 Abnormal electrocardiogram [ECG] [EKG]
• R94.4 Abnormal results of kidney function studies
• I25.2 Old myocardial infarction
• T46.5X6A Underdosing of other antihypertensive drugs,  [initial encounter]
• Z91.120 Patient’s intentional underdosing  of medication regimen due to  financial hardship
• Z01.810 Encounter for pre-procedural cardiovascular examination

EKG Coding Tips: Modifier – 26 Don’ts

Excerpt from: Coding tips: Modifiers -25, -26, and -59, Medical Economics Journal

When it comes to EKG billing, here are some don’ts to keep in mind:

DON’T apply it when there is a more specific code. For example, CPT code 93000 denotes a routine electrocardiogram (ECG) with at least 12 leads, including the tracing, interpretation, and report. If a physician performs only the interpretation and report (without the tracing), they should report CPT code 93010-not 93000 with modifier -26.

DON’T apply it when another physician already interpreted the test. Physicians can count their own interpretation toward their medical decision-making but not bill separately for the professional component of the test.

How Your Documentation Should Look

“EKG interpretation: Normal sinus rhythm with heart rate in the 60s. Normal axis. No LVH. No significant ST/T abnormalities are apparent. No significant change compared with the patient’s June 2015 EKG, as interpreted by me.”

Keep in mind, CPT guidelines state that there must be a “separate” report for EKG interpretation. Therefore, best practice is to ensure that your EKG interpretations have their own designated area or at least are within a separate paragraph in your charting.

Strive to Be Crystal Clear

With your EKG and Cardiac Monitor interpretations, it is important to be attentive to the language used in your charting. The phrase “as interpreted by me” is one of best practice. This notation clearly conveys to your coders (and payers) that you performed the work involved with the analysis. Contrast this to the phrase “as reviewed by me.” Charting such a statement implies you simply reviewed a report rather than performed the work involved in the analysis. Don’t disregard this — some payers may deny reimbursement for the service you have provided.

EKG Billing Services

Cardiologists often review electrocardiograms (EKGs) on behalf of hospitals or other physician practices.

This is a very important process for hospitals – in fact, it’s required by The Joint Commission, the nation’s leading healthcare accreditation organization.

But obtaining reimbursements can be tedious because of the large number of EKG billing claims and the relatively small payments per claim.

Here are a few other challenges and considerations with EKG billing and reimbursement:

Interfaces and Software

Typically when working with hospital interfaces two particular approaches are taken:

1. Duel interfaces – Most hospitals adopt a ‘demo interface’ as well as a ‘charge interface’.  This is adopted a lot of the time because it typically involves processes and/or interfaces that the hospital already has.  The difficulty is syncing up the two interfaces with one another and working within the appropriate frequency for both interfaces.  Additionally, items like diagnosis codes are more appropriate in the charge interface but are often placed in the demo interface.  EXPERT TIP: pay close attention to diagnosis codes in demo versus charge interfaces in order to get paid for the majority of the EKGs you read.
2. Single interface – While this option is a much cleaner approach, a single interface often requires custom programming by the hospital IT staff.  A thorough review of all the items included in the interface is necessary for you to appropriately bill.

Reconciliation

One of the most overlooked and yet necessary parts of any interface is a means of reconciling all the EKGs you read with all the EKGs you’ve received from the hospital.  It’s not unusual without a complete reconciliation review that a practice can miss 10% of their EKGs.  At First Coast Billing Group we’ve seen this get as high as 30%.

How To Optimize Your EKG Reimbursement

EKG reimbursement and Cardiac Monitor interpretations is not the same for all practices, with each site being subject to statute, regulations, and/or contractual agreements. This being noted, about 80% of Emergency Medicine practices submit EKG interpretations for financial reimbursement.

Based on 2018 AMA CPT designations, a 12 lead EKG interpretation (CPT code 93010) generates 0.24 RVUs. Within the framework of the 2018 Medicare Physician Fee Schedule, this translates to $8.64 per EKG interpretation. Many insurance carriers reimburse above this amount. Based on a 55,000 patient/year ER volume, consider the following: If you average eight EKG interpretations documented during a typical “main side” shift, you’ve generated $69.12 in the course of that shift. Now, if this site has six comparable shifts per day, that’s $414.72/day that stands to be realized. Over the course of a year, this group’s reimbursement potential is $151,372 for the year. Similarly, based on 2018 AMA CPT designations, a Cardiac Monitor Interpretation (CPT code 93042) generates 0.20 RVUs. Within the framework of the 2018 Medicare Physician Fee Schedule, this translates to $7.20 per interpretation. Some insurance carriers reimburse up to three to four times this amount. In a 55,000 patient year ER setting: eight Cardiac Monitor interpretations documented during a typical “main side” shift, will generate $57.60. Presuming this site has six comparable shifts per day, that’s $345.60/day and potentially $126,144.00 a year.

Not All Sites will Reimburse for EKGs

CPT guidelines allow for any qualified physician to code for a service they provide. Medicare, as well as some other payers, will reimburse for only one EKG interpretation as applicable for a single diagnostic service. It may happen that multiple providers perform an interpretation on the same EKG. For example, this occurs when the Emergency Medicine physician and the cardiologist reviewing a facility’s EKG both perform an interpretation on the same EKG. The clinician who gets reimbursed in this situation depends upon the policy of your payers, hospital guidelines, and/or contractual arrangements made by your physician group.

Which brings us to EKG diagnosis coding by payers. EKG monitoring procedures may be covered by private payers when medically necessary. Coverage guidelines and payment levels vary by payer and specific plan.

EKG Reimbursements: Medicaid & Medicare

EKG monitoring procedures may be covered by Medicaid programs when medically necessary. Coverage guidelines and payment levels vary by Medicaid program.

EKG monitoring may be used to detect cardiovascular disease or monitor an established cardiovascular disorder. Specific indications for coverage may vary by Medicare Contractor. Cardiovascular stress testing is generally covered by Medicare for symptomatic patients with known or suspected ischemic heart disease.

• Specific indications for coverage may vary by Medicare Contractor. Providers should refer to their Medicare Contractor’s Local Coverage Determinations for specific coverage and billing guidelines.
• All Medicare claims for cardiovascular stress testing should include primary and secondary ICD-10-CM diagnosis codes to support medical necessity for the procedure. The primary diagnosis code indicates the patient’s presenting symptoms or acute myocardial infarction. The secondary diagnosis code indicates the patient’s risk factors or disease process.