Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Medicare Reimbursement for 
Electroconvulsive Therapy 
JANET REHNQUIST 
Inspector General 
DECEMBER 2001 
OEI-12-01-00450  OFFICE OF INSPECTOR GENERAL 
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http://oig.hhs.gov/oei/  Janet Rehnquist

Inspector General

OIG Final Report:  Medicare Reimbursement for Electroconvulsive Therapy, 

OEI-12-01-00450

Thomas A. Scully

Administrator

Centers for Medicare & Medicaid Services

Purpose 
This memorandum recommends that the Centers for Medicare & Medicaid Services (CMS) 
consider the appropriateness of one of the two current procedural terminology (CPT) codes 
for electroconvulsive therapy (ECT).  Currently, ECT can be billed under 90870, Single 
Seizure; or 90871, Multiple Seizures, per day.  However, the National Institutes of Health 
(NIH) 1985 Consensus Conference Statement on ECT, as well as more current research, 
indicates that the administration of multiple seizures is not clinically recommended. 
Background 
Electroconvulsive therapy is a treatment for severe mental illness in which a brief application of 
electric stimulus is used to produce a generalized seizure.  Electrodes connected to an ECT 
machine are attached to the scalp of a patient who has received general anesthesia and a 
muscle relaxant.  The ECT treatments are generally given on an every-other-day basis for 2 to 
3 weeks.  Seizure lengths of duration of greater than 20 seconds per treatment (as assessed by 
motor activity, not electroencephalogram seizure activity) are considered adequate for 
therapeutic purposes.  According to the NIH 1985 Consensus Development Conference 
Statement on ECT, ...The number of treatments in a course of therapy varies.  Six to twelve 
treatments are usually effective.... 
The March 14, 2001,  Journal of the American Medical Association states that ECT is ...an 
effective and safe treatment for severe major depression...(it) may also be seriously considered 
as treatment for patients with acute mania, and for patients with schizophrenia who have not 
responded to adequate antipsychotic medications.... 
Medicare allowed charges for ECT in 1998, 1999, and 2000 were $13.3 million; $13.6 million; 
and $13.6 million, respectively.  The total allowed services were 154, 995 (1998); 153,193 
(1999); and 153,000 (2000).  Page 2 - Thomas A. Scully 
Issue - Medical Literature Does Not Support Use of CPT 90871 
According to the American Medical Associations CPT Assistant newsletter, Summer 1992, 
two CPT codes are available for billing Medicare for ECT services:  Code 90870, single 
seizure, and Code 90871, multiple seizures, per day.  (Note that multiple seizures is also 
known as multiple monitored ECT (MMECT)). 
Medicare allowed charges for CPT 90871 during 1998, 1999 and 2000 were $473,000; 
$464,513; and $435,000, respectively.  The total allowed services were 3,855 (1998); 3,788 
(1999); and 3,585 (2000).  The average allowed charge for CPT 90871 in 2000 was $121.00; 
for CPT 90870 it was $88.00. 
The NIH 1985 Consensus Development Conference Statement on ECT states that ...Multiple-
monitored ECT (several seizures during a single treatment session) has not been demonstrated 
to be sufficiently effective to be recommended... 
Notwithstanding this statement, CPT 90871 is being reimbursed by Medicare, as noted above, 
at the rate of about $500,000 per year. 
In 1997, we sought an opinion from a carrier medical director, who is also a psychiatrist, about 
Medicare ECT data.  He advised us as follows: 
...the use of 90871, multiple seizures in one day, should show a very small 
utilization...The technique of purposely inducing multiple seizures to increase the 
therapeutic benefit is rarely done, and is apparently only supported by anecdotal 
reports.... 
This carrier medical director believes that the frequent use of 90871 could be caused by 
practitioner confusion.  He states: 
...in the ordinary course of administering ECT, or in order for the treatment to be 
effective, the seizure needs to last more than 20 seconds.  If the seizure is of shorter 
duration, the seizure needs to be repeated until a seizure of sufficient duration is 
achieved.  This should be coded as  90870... 
Because the NIH Consensus Development Conference Statement on ECT was issued over 15 
years ago, we recently asked the National Institute of Mental Health (NIMH) for their opinion 
on the use of Code 90871 (MMECT).  Page 3 - Thomas A. Scully 
In a May 14, 2001 memorandum, NIMH made the following points.  In MMECT, the patient 
undergoes ECT in the usual fashion, but before gaining consciousness, undergoes another 
session of ECT designed to elicit a second (or additional) seizure.  There were three rationales 
for this:  (a) as a more intense treatment, MMECT would induce a faster therapeutic response; 
(b) if MMECT resulted in fewer inductions of general anesthesia by "doubling up" treatments, 
it would be safer for medically compromised patients; and (c) lower cost based on fewer 
treatment sessions. 
The modern use of MMECT is centered on clinical case series, supplemented with limited 
single-blind studies, to emerge from Oregon between the mid-1960s and the mid-1980s. 
Administering between 4 and 8 seizures, spaced 3 minutes apart, per session, the studies 
reported an equivalent efficacy between MMECT and standard ECT, while claiming the above 
cited advantages of reduced cost, lessened time ill, and lower general cognitive disturbances 
associated with MMECT.  However, other investigators were unable to verify the claimed 
advantages, and reports of prolonged seizures and profound confusional states following 
MMECT turned the field away from MMECT.  A key study was published (Comprehensive 
Psychiatry 1972; 13:115-121) that was definitive in showing none of the claimed benefits and 
many risks; the investigators concluded that MMECT was unacceptable. 
Recent objective reviews have concluded that MMECT should not be part of a routine clinical 
treatment.  A 1999 book entitled Electroshock:  Restoring the Mind  notes from the 
present-day perspective that the presumed advantages of MMECT (see list above) have in fact 
not been realized; the book concluded that "such schedules are not encouraged today. 
The second edition (2000) of the American Psychiatric Association Task Force on ECT's 
recommendations for clinical training and practice, published in the last 6 months, finds a role 
for MMECT only "rarely," and even then for no more than two seizures, far below the 4 to 8 
recommended by the advocates for MMECT.  There are accepted clinical grounds for inducing 
double seizures at a single session, including manic delirium and catatonia, where speed of 
clinical response is essential, and also in the case of an inadequate seizure resulting from a very 
high seizure threshold, where the patient is re-stimulated.  However, according to NIMH  
...This is not considered "MMECT," and there appears to be no reason to code this differently 
from regular ECT... 
The NIMH concluded that MMECT does not, in fact, have a scientifically demonstrated role 
and should not be done.  Specifically, NIMH noted that ...MMECT, while attracting 
advocates among some clinicians over the years, has never entered mainstream medicine.  Its 
role in modern psychiatric practice is marginal at best... the research supported and reviewed 
by NIMH does not provide evidence in favor of continuing a routine code for what is generally 
regarded as an outmoded procedure that should not be used in other than extraordinary 
circumstances.  Page 4 - Thomas A. Scully 
We did not review medical records to determine if multiple-monitored ECT claims which were 
paid for by Medicare were medically necessary and properly coded.  However, based on the 
1985 NIH Consensus Development Conference Statement and the comments from the carrier 
medical director and NIMH, the OIG believes that CMS should take steps to assure that 
Medicare coverage policy on ECT is consistent with current research and medical practice 
guidelines.  The CMS action on this issue would also address patient safety, as noted earlier, 
MMECT has the potential to do harm, i.e. to cause prolonged seizures and profound 
confusional states. 
Recommendations 
We recommended that CMS consider the appropriateness of Code 90871 and take the 
necessary action.  The CMS action should take into account, of course, that CPT 90871 
should rarely, if ever, be used. 
CMS Response 
The CMS concurred with our recommendation and indicated that it will review the 
appropriateness of CPT 20871 at the next quarterly review of CPT codes.  A copy of CMS 
response is attached as Appendix A. 
Attachment  APPENDIX A