Ensure Error Free Coding Strategies for Diagnostic Studies

The interpretation for X-rays calls for different approach as compared to EKGs. 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. 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. Basically, they do pay for the claim that the first claim submitted. That's probably a very high percentage of cases.

Suppose you have two claims for the same EKG, they will go ahead and pay for the first one that they have received. It’s rare for them to determine which one led to the diagnosis and treatment of the patient because they frankly don’t know that. The majority of claims that are submitted are done electronically. And they're in electronic transmission. There's nothing within that transmission which designates whether you are the one that interpreted that contemporaneous with the patient care. So it would be difficult from Medicare’s perspective to know which one. Though, they can always request a hard copy of the treatment record to determine which one was contemporaneous. Medicare requires that x-rays and EKGs should appear as a separate notation in the medical record. It's good to have that happily because it is a separate service that’s being provided. There are payers, who unhappily decide among themselves that they incorporate that with the E/M code. But it is not the proper way to adjudicate claims. Hence, when you're doing an interpretation of an EKG, or billing for x-ray interpretations, you would bill for them separately from your evaluation of management code.

Now, when we talk about what you need on the chart, you do not need to have a separate document. But the written reports can definitely be incorporated into the emergency department treatment record. But it really has to clearly refract in the interpretation and not a review of an interpretation. To cut the long story short, your written report does not have to be separate from the treatment record; it can be incorporated into the treatment record but it has to designate with the emergency physician. They didn’t interpret that. And that the interpretation is written there was provided by the emergency physician. So that's different than writing down an interpretation done by another physician. For example, you have got this patient that has a severely sprained ankle and you are waiting for the official x-ray report from the radiologist. You might have incorporated in your treatment record that you had visualize the x-ray and did not see any fracture or subluxation or dislocation and the radiologist via their report concurred with you. On the other hand, when we talk about cardiology perspective, there are times when you do call cardiology and to evaluate (inaudible) rhythms through (effort) evaluate the interpretation of the cardiogram whether they concur or not, you might as the emergency physician document your interpretation of the cardiogram.
But you might also mention this is may be even more medically legal that the cardiology, review the cardiogram, done at 12:35 pm and they concur with your interpretation.
In EKG interpretations, there are few important points to remember –

  • Rhythm
  • Rate
  • Axis
  • Intervals
  • ST segment changes
  • Comparison to prior EKG
  • Summary of clinical condition

The main intervals you look for from the physician perspective would be the PR interval which are both capital letters, the QRS interval, the QTC and that's the distance (inaudible) the beginning of the Q wave to the end of the T wave. It's called QTC. And then the ST segment but these are interval lengths and interval segments. Each one of these is something that can cost those to become abnormal.

So generally, when you talk about intervals, you should have them listed for the coders so they're aware that when a physician says, “The PR interval is .14 and normal is at the .2” is you'll have an idea that that's part of their interpretation.

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