An underlying principle of emergency medicine is that emergency physicians should bill for the services that they provide. When the services provided are interpretative rather than procedural, this principle remains unchanged. There has long been a reticence on the part of some emergency physicians to bill for the interpretation of EKGs and X-rays, despite the obvious fact that the emergency physician is providing the interpretive service in “real time” - by which is meant “contemporaneously with the patient’s presence in the emergency department” and “the interpretation that directly contributed to the diagnosis and treatment of the patient.” 

It is common practice for the cardiologist and radiologist, respectively, to perform a “quality assurance” re-interpretation of an EKG or X-ray that has already been interpreted in “real time” by the emergency physician. This re-interpretation is often performed hours to days after the patient has left the emergency department. Clearly, these are not “contemporaneous” interpretations.  

Medicare has long held that, if more than one diagnostic interpretive service is billed to Medicare (by two or more providers) then the Medicare carrier is to determine which interpretation “contributed to the diagnosis and treatment of the patient” and which “was actually quality control”. Medicare pays hospitals for all “quality control” functions separately under Medicare Part A - therefore, all interpretive services which are not “contemporaneous with the patient’s presence in the emergency department” and which do not “directly contribute to the diagnosis and treatment of the patient” do not qualify for Medicare reimbursement. 

While it is clear that, from an ethical and moral standpoint, the emergency physician’s “real time” interpretation has much more value than the “delayed re-interpretation” of a diagnostic study - and is the interpretation deserving of reimbursement - many factors may conspire to prevent emergency physicians from billing for interpretive studies. Cardiologists and radiologists usually have contracts with the hospital administration which provide for them to perform interpretive services for hospital patients for EKGs and X-rays, respectively, and that provide for compensation for these services - whether by permitting direct billing of third party and private payers by these specialists or by permitting the hospital to bill for these services and then providing reimbursement to these specialties for their services.  

These contracts are often cited as authority for cardiologists and radiologists to be the sole “billing entities” for these interpretive services. These arguments conveniently neglect the fact that these interpretations may not be contemporaneous with the patient’s presence in the ED and thus have only limited “quality assurance” value. Nevertheless, the ultimate element which determines whether or not the emergency physicians bill for their interpretations of EKGs and X-rays is usually the “political clout” of the emergency physicians versus that of the cardiologists and radiologists. If the cardiologists and/or radiologists are “heavier hitters” than the emergency physicians - and have the ability to influence whether or not the emergency physician group retains its staffing contract at the next renewal date - then the hospital administration may prohibit the emergency physicians from billing for their interpretive services, even though such billing is clearly justified. 

If your physician group has emerged victorious from this “interpretive services turf battle”, then it is important that each physician fully understand the requirements for documentation of these services. First, the interpretation must be exactly that, and not merely a ‘review” of a study previously interpreted by another medical professional. For any interpretive study, the interpretation must be “separately identifiable” within the medical record. This does not mean that a “separate piece of paper” is required, merely that the interpretation should be readily identifiable in a distinct portion of the emergency department medical record. The interpretation must thus be a “written” report, which must be “signed”. If the page of the medical record containing the report is signed, then this signature suffices (the signature is not required in the space immediately below the report). In the Medicare Carrier Manual of May 1997, it is stated, “an interpretation and report should address the findings, relevant clinical issues, and comparative data when available.”