Billing and Coding: Electrocardiograms

The following billing and coding guidance is to be used with its associated
Local Coverage Determination.

**Coding Guidelines:**

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.

**Documentation Guidelines:**

Supportive documentation evidencing the condition and treatment is expected to
be documented in the medical record and be available upon request.  
  
An interpretation and report must address the findings and comparative data,
if available (i.e., a prior ECG).  
  
The patient's medical record must be legible and clearly indicate the
reasonableness and necessity of the service.  
  
The documentation must show that the service was reasonable and necessary for
at least one of the covered conditions in this policy.  
  
A laboratory or a portable X-ray supplier that supplies an ECG must maintain
in its records the referring physician's written order and the identity of the
employee taking the tracing.  
  
Patients presenting with an acute ischemic episode may require several ECGs on
one or more days to delineate the severity and progression of that episode
when needed to properly treat the patient.  
  
Unstable patients (e.g., electrolyte imbalance, recurrent rhythm disturbances,
recurrent chest pain) may require more than one ECG annually to diagnose the
condition or assess response to treatment.  
  
Typically, patients with chronic stable heart disease, or other diseases
potentially affecting the heart do not require an ECG more frequently than
annually.