ACEP, as a signatory society in the medical societies’ class settlement with Humana, has finalized an agreement for payment of diagnostic interpretations in the emergency department.

After a formal compliance dispute filed by ACEP in 2009, Humana has ceased bundling claims for CPT 93010 (12-lead ECG) diagnostic interpretations when reported with emergency department E/M code set (CPT 99217, 99218, 99220, 99234, 99235, 99236, 99281-99285, 99291, and 99292) as of April 16 , 2010 (Effective Date). Humana will reimburse one professional interpretation as of the Effective Date, and the first claim received for a 12-lead ECG will be reimbursed.

Humana has also agreed to pay resubmitted ECG interpretations for dates of service from Oct. 1, 2009, until March 31, 2010, provided that the claim resubmissions are filed by Feb. 1, 2011, and were not previously reimbursed by the patient. Claim resubmission is not contingent on participation status and must follow the spreadsheet format that will be posted on the ACEP Web site in the “Practice Resources” section.

This is significant in that Humana has agreed to pay the claims going forward and is allowing a retrospective reprocessing period of 6 months. However, emergency physicians must resubmit their claims (pursuant to the above-described spreadsheet format) within a 90-day window beginning Dec. 1, 2010.

Based on the Aetna settlement for payment of ECGs also negotiated by ACEP, payment for CPT code 93010 typically ranges between $10 and $15, so this can mean significant incremental reimbursement for physician groups.

ACEP was able to negotiate this settlement with Humana because of help from members in identifying the issue and providing proof of the denied claims. Similar disputes are in the works with Anthem/WellPoint and BlueCross/BlueShield plans in seven states.

If you have a problem with a payer inappropriately bundling separately reportable services into your E/M code, let ACEP know using the Billing Hassle Log found on the ACEP Web site at www.acep.org/membersurvey.aspx?formid=43460. You will be asked for the name of the payer and the state, along with the problem encountered.

Contact the ACEP Reimbursement Department for more information at dmckenzie@acep.org or 800-798-1822, ext. 3232.