Specialty is not the primary factor considered when payment is made for an interpretation of an EKG or X-ray done in the Emergency Room (ER). Payment will be made for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient. The interpretation billed by the specialist or radiologist is payable if the interpretation of the procedure is performed at the same time as the diagnosis and treatment of the beneficiary or if it is the only bill received. More than one interpretation on the same EKG or X-ray may be allowable under unusual circumstances.
The professional component of a diagnostic procedure furnished to a beneficiary in a hospital includes an interpretation and written report for inclusion in the beneficiary’s medical record maintained by the hospital. The interpretation and report of the procedure is separately payable. A “review” of the findings of these procedures, without a written report, does not meet the conditions for separate payment of the service since the review is already included in the ER visit.
Hospitals are encouraged to work with their medical staffs to ensure that only one claim per interpretation is submitted. The Medicare contractor may determine that the hospital’s “official interpretation” is for quality control and liability purposes only and is a service to the hospital rather than to an individual beneficiary. Separate payment will not be made for interpretations that are done solely for quality control purposes.