Claims and appeals for CPT 93010 performed in emergency room setting
First Coast continues to receive multiple claims for CPT 93010 (Electrocardiogram report) pertaining to the interpretation performed for the same Electrocardiogram performed on the patient on the same date of service in the emergency room. This results in the first claim paying and subsequent claim to deny as a duplicate.
According to the CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 13, Section 100.1 the standard procedure is to pay the first claim received. However, we are also required to pay for the interpretation and report that directly contributes to the diagnosis and treatment of the patient. Furthermore, second interpretations are only paid under unusual circumstances, such as when the initial interpreting physician deems that another physician's expertise is necessary due to a questionable finding or when a diagnosis has changed because of a second interpretation of the procedure's results. Claims for second interpretations must include modifier 77 on the claim, and documentation must substantiate the service billed with the modifier.
Changes to appeals process for CPT 93010
Effective May 9, 2025, First Coast will maintain the practice of paying the first claim received for CPT 93010 and denying subsequent claims; however, our processes are changing for appeals.
If First Coast receives an appeal for a denied claim for CPT 93010, we will review the documentation to determine whether the provider reporting 93010 directly contributed to the patient's diagnosis and treatment. If the appeal is deemed favorable, the appeals department will initiate the recoupment of the initially received and approved claim.
Once the claim adjustment is executed and recoupment is initiated, the provider of the initially processed and approved claim may appeal the overpayment with medical documentation demonstrating the second interpretation directly contributed to the patient's diagnosis and treatment in the emergency room (ER). A second interpretation may be requested due to a questionable finding by the initial physician and another physician's expertise was warranted to treat the patient in the ER or there is a changed diagnosis resulting from the second interpretation. Specifically, the documentation should not indicate the second interpretation was done for hospital quality purposes and did not contribute to the patient's diagnosis and treatment in the emergency room setting.
Appropriate use of modifier 77
Modifier 77 is used on subsequent claims for CPT 93010 when a second interpretation is necessary for the treatment of the patient. The claim submission for the second interpretation and use of the modifier 77 is appropriate only when it directly contributes to the patient's diagnosis and treatment. The modifier 77 is inappropriate when used for interpretations completed due to quality checks as part of hospital policies.
Example of appropriate use: The modifier 77 would be appropriate if the ER physician performs the first interpretation and requests the consultation of a cardiologist. The cardiologist performs a second interpretation, directly contributing to the patient's diagnosis and treatment. Both the ER physician and cardiologist would document their interpretations and involvement in treating the patient. The claim for the second interpretation would be submitted with the modifier 77.
For additional information on the appropriate use of modifier 77, review the below references: