Tuesday, September 14, 2004

Billing for your Group’s ECG Interpretations: Decision-making at the Intersection of Power and Money

Are you billing for ECG interpretations? Are you being paid? Have you been billing for years or did you just start recently? Increasingly emergency physicians are submitting bills for ECG interpretations for payment by third party payers, both commercial and governmental. Since you and your colleagues are doing the work of interpreting the ECG and making the decisions that directly affect the patient, its right that you be paid. But, uh oh, here comes a cardiologist in high dudgeon.

Advance notice of a change in billing practices, a “no surprises” policy, would have alerted your administration and other interested parties—such as that cardiologist—that you intended to begin billing for the work you and your staff are doing: interpreting the ECG and making the relevant clinical decision.

The Centers for Medicare and Medicaid Services (CMS formerly HCFA) has been quite clear in saying:

“In the case of a licensed physician who has furnished a covered service (that is not payable through another code) to a Medicare beneficiary in an emergency room, it is not readily apparent to us upon what basis the claim can be denied. There is no portion of the Act upon which to base a decision that only board-certified radiologist can furnish x-ray interpretations or board-certified cardiologists can furnish EKG interpretations. (Where the Congress has determined that there should be special qualifications in order to furnish a service, as in the case of mammography, a provision was made in the statute.) Our proposed policy for x-ray and EKG interpretation is consistent with how we generally treat other physician services.”

So there’s no question you’re well within the law in billing and pursuing collection for ECG interpretation and reporting. There are many sources of information on requirements and process for billing for ECG interpretation, one of these on the ACEP website includes information on all aspects of the law, regulations and billing process. Query your billing service and find out if they are billing for other of their customers. Certainly a consultant can help but is probably not necessary. I won’t elaborate on the process here since I’d rather discuss the leadership and change-management opportunities and pitfalls.

But in billing as in life just because a thing is possible, doesn’t mean it’s the right choice. Is billing for ECG interpretation and reporting the right choice for you at your hospital? I raise the question because just as with politics, so too all EDs are “local”. Your local practice environment, your relationship with the medical staff and your relationship with hospital administration may all factor in to a decision whether or not to bill for ECG interpretation.

First you should evaluate just how much will you make by billing for ECG interpretations. What’s the likely collection for the ECGs you presently perform. Look to your billing database or if ECGs aren’t separately tabulated there, sample your charts and count the number of ECGs done and look at the payer mix and the patient dispositions for those patients who have ECGs. That way you’ll know how much revenue you’ll collect from each payer and for admitted vs. discharged patients.

Now that you know the potential gain, consider the relationships and what you may lose in those relationships when you pursue the additional revenue, billing for ECG interpretation will bring your practice.

For example, as I write some New Yorkers are avidly watching the musical chairs game playing out among hospitals and their cardiac catheterization groups. One name group relocated recently and now several others are reportedly “in play.” While the $9-10 per ECG that Medicare pays (and comparable amounts from other payers) doesn’t seem like much of a “loss” to a cardiology group, it’s not the money that’s really the issue, it’s the image—and power. Relinquishing income to the “ER group” is not something you’ll find much support for when your hospital CEO is negotiating to keep a busy invasive cardiologist happy and on staff.

Alternatively, you could approach your cardiologists yourself. Rather than demand that they forgo billing for ECG interpretation for your patients, suggest a consulting arrangement for the purpose of assuring the quality of the emergency physician ECG interpretations. Offer a fixed rate, perhaps as little as $2-3 for over-reading of your interpretations as the studies flow into your hospital’s ECG filing system and medical records. No, they won’t be happy about the reduction in income, but you’ll get a hearing and using the information on the ACEP and CMS websites you may be able to persuade them that they face some risk of fraud allegations. At least you’re offering a way for them to preserve some of the ECG income.

In most environments, the issue will really be just about the money and in that setting you’ll have to carefully undertake an educational approach to the regulation and payment policies of CMS with regard to electrocardiography in the ED. In any case, simply implementing the change and precipitating the likely consequent shouting match across the hospital CEO’s desk isn’t the best plan for though you may prevail in this instance, the ill-will generated can only hurt you and your colleagues in the long run. Yes, the money matters, but so does the way you claim it.

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