X-Ray - EKG FAQ

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.  In addition, ACEP obtained documentation from the AMA CPT Director of CPT Coding and Regulatory Affairs in 2009 that the CPT 93010 “is not considered to be part of a given level of E/M service.” (emphasis in the original).

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. See 42 CFR 400, et al (Dec. 8, 1995) 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. See 42 CFR 400, et al (Dec. 8, 1995) 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" or “ECG negative” are  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.

See Medicare Claims Processing Manual Chapter 13 Section 100 

"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 not be appropriate 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. You should review local payer policies on a regular basis.

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:

1. Have a specific order for the diagnostic test
2. Have documentation in the medical record supporting the need for the diagnostic test
3. Have a separate, signed, written and retrievable report; and an interpretation of the diagnostic test

In addition, Rhythm ECG services are appropriate when:

4. The order for the diagnostic test is triggered by an event
5. The diagnostic test is used to help diagnose the presence or absence of an arrhythmia

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 local coverage determinations 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.

No. Per CPT, “The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service.”

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-10 screens to review claims for "medical necessity." Unless the claim contains an ICD-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 websites, 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.

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.  See 42 CFR 400, et al (Dec. 8, 1995) 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. 

CPT lists 19 services that are included in critical care. CPT states that two specific chest X-ray interpretations (CPT codes 71045 chest single view frontal and 71046 chest two views frontal and lateral), interpretation of cardiac output measurements, pulse oximetry, blood gasses, gastric intubation, temporary transcutaneous pacing, ventilatory management, vascular access procedures and information stored in computers. Collection and interpretation of physiologic data (e.g., 3-lead ECGs for rhythm, blood pressures, hematologic data are considered "bundled" into critical care and as such may not be coded separately. CPT states “Any services performed that are not listed above should be reported separately.” Interpretations of X-rays other than CPT 71405 and 71406 may be coded in addition to Critical Care Services. Because the reference to ECGs describes physiologic data (such as 3-lead ECG continuous monitoring) and does not specify any cardiography codes, code 93010 for the interpretation and report of a 12 lead ECG may be coded in addition to Critical Care Services.

Some payers may have 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, per Medicare’s Claims Processing Manual 1-18-24, section 20.3.E, CMS will make a separate payment for an EKG interpretation. However, under CMS's "Correct Coding Initiative" (CCI), Medicare does not allow the combined use of Critical Care Services and rhythm EKG 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 reimbursement@acep.org.