Cardiology Coding Alert

Correct E/M Code Critical to Reimbursement for ED Cardiology Visits

Seeing patients who present with chest pains in the emergency department is par for the cardiologists course.

But from which category of Evaluation and Management (E/M) services codes do you select: office or other outpatient, emergency department, hospital inpatient, consultations or critical care?

Without an adequate understanding of a cardiologists role in the ED and how to code for it, you could be shortchanging your practices revenue, not to mention asking for an audit, say national experts in E/M coding.

Here are five tips to help you pick the right E/M code for your cardiologists in the emergency department:

1. Know the difference between a consult and transfer of care.
Improperly billed consultations are high on the HCFA fraud and abuse list, cautions Thomas Kent, CMM, seminar leader for McVey and Associates, and president of Kent Medical Management in Nevada, CA.

Auditors, who are checking to see if services should have been downcoded from a consult to an outpatient visit, have been winning a lot of money, he says. However, you dont want to automatically downcode, because your practice is ethically entitled to bill for true consults. First, check the documentation and talk with the cardiologist. For example, look and listen for the following key components of a consultation as stated in the CPT manual:

The request for consultation from the attending ED physician must be documented in the patients record.

In the course of rendering that opinion, a consulting specialist may initiate therapeutic treatment, order diagnostic tests and perform services. The results must then be communicated back to the requesting ED physician in a written or verbal report. (Although the CPT Codes does not specify which form the communication must take, it should be documented in the patients record by both the cardiologist and the ED physician.)

Also, remember that HCFA has a different definition of the term consultation than CPT. HCFA does not have to go by the CPT Guidelines, and they are the ones doing the auditing, warns Steve Arter, executive vice president in the compliance and education division, QuadraMed Corporation, Point Richmond, CA.

Section 15506 of Medicare clearly states that a consultation is advice only, he says. To be on the safe side, make sure there is documentation between the ED physician and the cardiologist showing the initial request for consulting as well as the additional request to treat. Such a paper trail, notes Arter, could keep you out of trouble if HCFA auditors try to interpret the initiation of treatment as transfer of care.


Tip: Dont rely on the word referring in the chart to identify a consult from transfer of care. Even if you check the chart and it says Thank you for referring ... that word may be used improperly, Kent warns. HCFA will see the word referral and wonder why you are billing for a consult.

In fact, he advises coders and cardiologists to wipe the word referral from their vocabularies. It is commonly used inaccurately to mean requesting, but the actual meaning is transfer of care, he explains. Instead, Kent suggests that you begin your letters of findings as follows:
Thank you for your request to render an evaluation of _________ (patients name) for _________ (condition).

2. Turf conflicts can affect reimbursement.
If the ED physician calls in your cardiologist to interpret EKG or chest x-rays, then your practice should be the one to bill for the test interpretation, not the ED physician.

However, it is not always that simple. Problems may occur because some hospitals have a policy that a cardiologist or radiologist must reread the results of an EKG or chest x-ray as a quality assurance measure. In that case, both the ED physician and the cardiologist might end up submitting a bill for the reading of the same test.

Medicare, however, wont get involved with hospital policy. We will only pay for one claim, and thats the one that gets here first, says Georgia Medicare director, F.D. Maner.

Tip: Before billing, check to see what arrangement or contract the hospital has with its local cardiologists or radiologists to read tests performed at the facility.

3. Use ED services codes correctly.
How do you code if the cardiologist meets the patient directly in the ED? If the patient never sees the ED physician, then your cardiologist would be, for Medicare purposes, acting as the ED physician. In that case, you would report 99281 to 99285 (emergency department services), because the ED physician did not take part in the patients treatment.

If you do use ED codes, make sure you arent billing at too low of a level. For example, in a regular office setting, a level 5 service requires a comprehensive history.

But a patients condition and/or mental status in the ED may be too urgent for the cardiologist to perform such a comprehensive history or exam. In these instances, you can still code a 99285 if you document these constraints.

Note: Remember, in the ED code category, there is no distinction made between a new or established patient.

4. Code correctly if you see patients in a freestanding facility.
The same rules regarding levels for ED codes dont apply if you see patients in a freestanding ambulatory care or urgent care center. In fact, you cant use the ED codes at all because these facilities dont meet the definition of an emergency department, An organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. The facility must be available 24 hours a day. Depending on the level of service rendered, use office or other outpatient service codes (99201-99215).

5. Know when to report critical care codes.
Suppose the cardiologist instructed the patient, who was complaining of chest pains, to meet him or her at the ED. Before the cardiologist can do a traditional history and exam, the patient develops a myocardial infarction (MI) and goes into cardiac arrest. If the cardiologist provided the critical care, then he or she gets to bill for it, using the critical care codes (99291 -99292).

One common question relating to the above scenario of cardiac arrest is: Can the cardiologist bill for 92960 (cardioversion, elective, electrical, conversion of arrhythmia, external, in addition to critical care)?

The answer is maybe. Some carriers consider defibrillation procedures an integral part of the critical care service and thus would not pay for them separately. So check with your local carrier.

However, you can code for both critical care services and 92950 (cardiopulmonary resuscitation) -- but only if the cardiologist is serving as the patients primary physician in the emergency department.

Likewise, in some instances, you might also be able to code for 92977 (thrombolysis, coronary; by intravenous infusion). However, some carriers may reimburse the hospital for this procedure, and not the cardiologist. The rationale is that the nurse monitors the infusion, rather than the physician.

Tip: In the majority of the cases, as soon as the cardiologist shows up and the ED physician signs off on the patient, care is transferred to the specialist. So the cardiologist should not code the service as a consult, but either as a hospital admission or an outpatient visit. If you use the latter, be sure to indicate the site of service as the emergency department.