Charge Up Your ECG Documentation
Be sure the medical record carries enough voltage to bypass reimbursement challenges.
Physicians often use computer-generated electrocardiogram (ECG) reports as the baseline for their own interpretation and report. Computer-generated ECG reports, alone, do not meet the requirements to code and bill for the professional component of an ECG. The Centers for Medicare & Medicaid Services (CMS) requires a “separate” interpretation report and signature from the ordering provider. Additionally, applying modifiers to ECG codes inappropriately may lead to reimbursement challenges.
Note: The CPT® codebook includes several types of tests within the Cardiography section. In this article, we will concentrate on “routine” ECG codes 93000-93010.
Routine ECG Reporting
Services described by 93000-93010 generally involve placement of six leads on the patient’s chest, and another six leads placed between the patient’s extremities. The heart’s electrical activity generates a current that spreads to the skin; electrical activity sent from the sinoatrial node through the heart is traced/recorded and reviewed.
You should not apply modifiers 26 Professional component or TC Technical component to these ECG codes because CPT® has already broken down 93000-93010 into professional and technical components, as shown below.
93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report
This code reports the global professional and technical components of the service. Use 93000 if the equipment belongs to the ordering provider. Note that an ECG with interpretation must include the full graphic tracings with formal written interpretation
93005 Electrocardiogram, routine ECG with at least 12 leads, tracing only, without interpretation and report
Use this code for ECG without the interpretation and report (technical component). Documentation should include the serial tracing.
93010 Electrocardiogram, routine ECG with at least 12 leads, interpretation and report only
Report 93010 for the professional component of the ECG only. You should not apply modifier 26 when there is a specific code to describe only the physician component of a given service. For example, when a cardiologist provides an ECG interpretation at a hospital with a separate report, the correct code is 93010. Do not code 93000-26.
Meeting ECG Order Requirements
A valid ECG order will have the following attributes:
- A specific order for the diagnostic test
- Documentation in the medical record supporting the need for the diagnostic test
- A separate, signed, written, and retrievable report with an interpretation of the diagnostic test
- The order for the diagnostic test, triggered by an event
- The diagnostic test to help diagnose the presence or absence of an arrhythmia
- An electronic signature or some indication on the results for all tests
- An indication that the ordering provider reviewed the results (or the provider must indicate this in the note)
Warning: If there is no evidence that the ordering provider reviewed the results, or there is no mention of the ECG results in the note, you can’t code for the ECG.
Best Practices to Document
the Physician Report
As far back as 1992, the CPT® codebook has included language stating, “a written report, signed by the interpreting physician, should be considered an integral part of a radiologic procedure or interpretation.” Medicare law (42 CFR § 415.120(a)) likewise requires all interpretation services to be documented in “a written report prepared for inclusion in the patient’s medical record maintained by the hospital.”
CMS does not require the provider to document an ECG interpretation on a separate piece of paper, but instead allows for a complete written interpretation to be recorded within the medical record (check with your local carrier for further guidance). CMS further requires a report to be complete, documented similarly to that of a specialist in the field (radiology), and consistent with the treatment rendered. CPT® states there must be a “separate, signed, written, and retrievable report.”
Common ECG documentation errors:
- CMS differentiates between an interpretation with report and a simple review. An interpretation with report must include findings, relevant clinical issues, and comparative data (if available).
- Simply notating “ECG normal” would not suffice for separate payment consideration under an audit. This sort of documentation is a review of findings, only, which is inclusive to any E/M service reported.
Documentation best practice of common ECG findings may resemble the following examples:
- Sinus tachycardia, rate 120, non-specific ST-T changes, no acute ischemia noted, no EKG available for comparison.
- Normal sinus rhythm with rate of 72, PR and QRS intervals within normal limits, QRS complexes in lead III and T-wave abnormalities in lead I, no acute changes noted from prior EKG.
- Right bundle branch block, no ischemic changes.
Compliance Coding Tip: Do not code for ECG or rhythm strip interpretation if the physician merely notes, “EKG normal or negative.”
Problem Areas to Watch
For examples of where ECG claims can fail, consider that Novitas Solutions performed a 100 claim sample of ECG services in a post pay audit and found a 22 percent claim error rate and a 17 percent claims paid error rate. The majority of the errors were in the following areas:
- Missing order from the “ordering provider” and no supporting diagnosis for the ECG
- Missing ECG documentation – no signed review of the actual test, and/or no signed interpretation/report
- Incorrect billing of ECG – billing an ECG without a supporting diagnosis, wrong CPT® code
Clinical ECG Coding Example
A 65-year-old, obese female patient presents to ED via ambulance with an acute onset of chest pain. No prior cardiac history. Patient was walking her dog at the onset of event. EKG was performed or read by the ED physician. Separate notation of EKG results are in the chart. “Sinus tachycardia, rate 120, non-specific ST-T changes, no acute ischemia noted, no EKG available for comparison.” The patient was discharged with orders to follow up with Dr. Cardiologist within three days. No medications prescribed at this time, other than OTC aspirin 85 mg bid, a.m. & p.m.
Lab work performed and patient admitted. Full H&P.
Code – E/M MDM management options = 4 points for additional work
Data reviewed = 3 points for order and read of EKG + 1 point for lab
Risk = High for acute chest pain and age of patient, obesity
99285 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity.
Dx Can Make or Break Your Claim
The diagnosis code must establish the medical necessity of an ECG. If diagnosis coding is not precise, or if the medical record does not support a diagnosis code, some carriers will consider the ECG “routine” and will deny payment for ECG interpretation.
To learn more about ECG documentation, view the ACEP website: www.acep.org/Legislation-and-Advocacy/Practice-Management-Issues/Physician-Payment-Reform/X-Ray—EKG-FAQ/
For CMS guidelines on ECGs, go to: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c13.pdf
Holly Cassano, CEO, CPC,is AAPC ICD-10-CM Certified, director of coding education and compliance for Tactical Management Inc., (TMI). She is a member of the Tampa, Florida, local chapter.