The electrocardiogram (ECG, EKG) and ECG rhythm strip records the electrical
activity of the heart throughout the cardiac cycle of contraction
(depolarization) and relaxation (repolarization). The changes in electrical
potential during the cardiac cycle are detected at the body surface and
recorded on graph paper. The recording is reviewed by a physician who provides
an interpretation and written report. An ECG may be reported as the technical
aspect only, the interpretation and written report only, or both aspects
together as one service.  
  
The electrical activity of the heart can be viewed along various electrical
axes (viewpoints). Each viewpoint is described as a "lead". A typical ECG
views the heart from 12 axes and, therefore, has 12 leads. A rhythm strip
typically includes one to three leads. Typically, a 12-lead ECG is a separate
document from the medical progress notes, while a printed rhythm strip may be
pasted into the progress notes.  
  
An ECG is indicated to diagnose or treat a patient for symptoms, signs, or a
history of heart disease; or systemic conditions that affect the heart,
including:

  * Chest pain or angina pectoris,
  * Myocardial ischemia or infarction,
  * Arteriovascular disease including coronary, central, and peripheral disease,
  * Hypertension,
  * Conduction abnormalities,
  * Cardiac rhythm disturbances,
  * Cardiac hypertrophy,
  * Heart failure,
  * Pericarditis,
  * Structural cardiac conditions,
  * Endocrine abnormalities,
  * Neurological disorders affecting the heart,
  * Syncope,
  * Paroxysmal weakness,
  * Palpitations,
  * Sudden lightheadedness,
  * Electrolyte imbalance,
  * Acid-base disorders,
  * Temperature disorders,
  * Pulmonary disorders, and
  * Drug cardiotoxicity.

  
An ECG may help identify cardiac disorders as part of a preoperative clinical
evaluation. A preoperative ECG may be reasonable and necessary under one of
the following conditions:

  * In the presence of pre-existing heart disease such as congestive heart failure, prior myocardial infarction (MI), angina, coronary artery disease, or dysrhythmias;
  * In the presence of known comorbid conditions that may affect the heart, such as chronic pulmonary disease, peripheral vascular disease, diabetes, or renal impairment; or
  * When the pending surgery requires a general or regional anesthetic.

  
The results of the ECG must be relevant to the management of the patient.  
  
When an ECG is performed on the same day as a cardiac stress test, but is not
part of that stress test, it is separately payable. The ECG must add
additional information to the stress test. For example, an ECG may be
reasonable and necessary to rule out an acute MI prior to a same day stress
ECG performed to evaluate possible accelerating angina. Typically, when the
ECG stress test is scheduled in advance, a separate ECG on the same day is not
reasonable and necessary.  
  
An ECG is not a covered benefit when used for screening purposes or as part of
a routine physical examination. Routine physical examinations (screening) are
evaluation and management services supplied in the absence of associated
signs, symptoms or complaints. These services are denied as not a benefit of
the Medicare program. Patients may choose to pay privately for these services.  
  
A second ECG performed to replace a technically inadequate ECG may not be
reported as an additional service.  
  
Rhythm ECGs are used to evaluate signs and symptoms that may reflect a cardiac
rhythm disorder.  
  
A rhythm ECG interpretation and report only (93042) is included in a 12-lead
ECG interpretation and report (93000 or 93010).  
  
A rhythm ECG tracing (93040 or 93041) is included in a 12-lead ECG tracing
(93000 or 93005).  
  
When several ECG rhythm (or monitor) strips from a single date of service are
reviewed at a single setting, report only one unit of service, regardless of
the number of strips reviewed.  
  
If one physician bills a rhythm strip interpretation, and another physician
bills an ECG interpretation for the same patient on the same date of service,
then both services must be reasonable and necessary. Typically, the patient
will receive and require **prolonged** rhythm monitoring in addition to a
12-lead ECG.  
  
An ECG furnished on an **emergency** basis by a laboratory or a portable X-ray
supplier requires that a physician be in attendance at the time the service
was performed or immediately thereafter.  
  
Payments for a home-based ECG above the ECG base amount (i.e., for
transportation costs) requires a medical need for performing the service in
the patient's home, in addition to the need for the ECG itself. Typically,
qualifying patients will be homebound or bed-confined.  
  
Payment for the technical component of an ECG will be denied when the facility
is paid for the technical component through the fiscal intermediary (i.e.,
during a Part A covered nursing home stay). In these cases, the ECG supplier
is paid by the facility under a contract arrangement.  
  
 **Payment for more than one Professional Component (PC) of a single ECG:**  
  
Medicare will not pay twice for a service that is required only once to
diagnose or treat an illness or injury. Typically, this A/B MAC will pay for
only one PC of an ECG. This A/B MAC may pay for a second PC when the
additional physician expertise is necessary and reasonable to diagnose or
treat the patient, such as to clarify a questionable finding. The physician
performing the initial PC must have a valid reason to require another
physician's expertise, such as, to interpret a confusing ECG. The second
physician's knowledge and expertise must be significantly greater than that of
the first reader, and it must contribute substantially to the interpretation.  
  
**Multiple Interpretations of a Diagnostic Test in Institutional Settings:**  
  
Medicare generally pays for only one reading of a diagnostic test. Medicare's
rules are clearly explained in the Internet-Only Manual, Pub. 100-04, Medicare
Claims Processing Manual, Chapter 13, Section 100.1 which made clear with
public notice and comment that CMS policy would not pay for routine second
readings). While Chapter 13 is titled, "Radiology Services", Section 100.1 is
titled "X-rays and EKGs furnished to Emergency Room Patients." The principles
apply to double-readings of diagnostic tests in general. The following
paragraphs quote extensively from Section 100.1. [ _Emphasis added by this A/B
MAC_ ]

_**Generally, A/B MACs (B) must pay for only one interpretation of an EKG** or
x-ray procedure furnished to an emergency room patient. They pay for a second
interpretation (which may be identified through the use of modifier "-77")
**only under unusual circumstances** (for which documentation is provided)
such as a questionable finding for which the physician performing the initial
interpretation believes another physician's expertise is needed or a changed
diagnosis resulting from a second interpretation of the results of the
procedure. When ___A/B MACs (B)_ receive only one claim for an interpretation,
they must presume that the one service billed was a service to the individual
beneficiary rather than a quality control measure and pay the claim if it
otherwise meets any applicable reasonable and necessary test.  
  
**When**_ _ ** _ _A/B MACs (B)__ receive multiple claims for the same
interpretation**, they must generally pay for the first bill received. ____A/B
MACs (B)__ must pay for the interpretation and report that directly
contributed to the diagnosis and treatment of the individual patient.
Consideration is not given to physician specialty as the primary factor in
deciding which interpretation and report to pay regardless of when the service
is performed. Consideration is not given to designation as the hospital's
"official interpretation" as a factor in determining which claim to pay.
____A/B MACs (B)__ pay for the interpretation billed by the cardiologist or
radiologist if the interpretation of the procedure is performed at the same
time as the diagnosis and treatment of the beneficiary. (This interpretation
may be an oral report to the treating physician that will be written at a
later time.) [End quotations]_

Section 100.1 provides one example of a medically appropriate "double payment"
for a second interpretation, an example where an ER physician diagnoses
pneumonia but a radiologist provides a requested second reading for possible
tumor. For double reading of an EKG, a similar circumstance must apply, an
unusual reason why a second interpretation (for example, a reading by a
cardiologist) was specifically medically necessary. Otherwise, the second
interpretation must be denied per the manual as a "quality control service."

Alternatively, if the first physician defers diagnosis with a telegraphic note
and passes the test to the second physician for his/her diagnostic
interpretation, only the second physician should bill. Chapter 13, Section
100.1 states that a telegraphic note in an E/M record is considered part of
the E/M service and not a separate report. For example, a treating physician
may see an x-ray with a radiologist's report of a fractured tibia, and he may
note "x-ray, fx tibia" in his E/M summary, but he may not charge an additional
"radiologic interpretation" fee. The CMS manual states as follows:

___A/B MACs (B)__ generally distinguish between an "interpretation and report"
of an x-ray or an EKG procedure and a "review" of the procedure. A
professional component billing based on a review of the findings of these
procedures, without a complete, written report similar to that which would be
prepared by a specialist in the field, does not meet the conditions for
separate payment of the service. This is because the review is already
included in the emergency department evaluation and management (E/M) payment.
For example, a notation in the medical records saying "fx-tibia" or EKG-normal
would not suffice as a separately payable interpretation and report of the
procedure and should be considered a review of the findings payable through
the E/M code. An "interpretation and report" should address the findings,
relevant clinical issues, and comparative data (when available). [end
quotation.]_

Each payable interpretation must include a complete, written report similar to
one that is prepared by a specialist in the field. The content of the written
report must address the relevant clinical issues, available comparative data,
and test findings. The format of the report must be separately identifiable.
It may be included under a separate heading within the clinical record or
written on the ECG tracing itself, with a reference in the clinical record.

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