Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JANET REHNQUIST 

Inspector General 

DECEMBER 2001 

OEI-12-01-00450 

Medicare Reimbursement for 

Electroconvulsive Therapy 
OFFICE OF INSPECTOR GENERAL 

The mission of the Office of Inspector General (OIG) mandated by Public Law 95-452, as 

amended by Public Law 100-504, is to protect the integrity of the Department of Health and 

Human Services programs as well as the health and welfare of beneficiaries served by them. This 

statutory mission is carried out through a nationwide program of audits, investigations, 

inspections, sanctions, and fraud alerts. The Inspector General informs the Secretary of program 

and management problems and recommends legislative, regulatory, and operational approaches to 

correct them. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 

Inspector General. It conducts short-term management and program evaluations (called 

inspections) that focus on issues of concern to the Department, the Congress, and the public. The 

inspection reports provide findings and recommendations on the efficiency, vulnerability, and 

effectiveness of departmental programs. 

OEI's headquarters office prepared this report under the direction of Stuart Wright, Director, 

Medicare and Medicaid. 

Headquarters 

Alan Levine 

Senior Program Specialist 

To obtain copies of this report, please call our headquarters office at (202) 619-0480. 

Reports are also available on the World Wide Web at our home page address: 

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 Association’s 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 “...Multiplemonitored 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