Electrocardiogram (ECG or EKG) - CPT 93000, 93005, 93010 - WHEN TO USE

Procedure code and description

93000 - Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report -average fee amount-$10-$20

93005 - Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report


93010 - Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only - Average fee payment $3 - $10

93040 - Rhythm ECG, 1-3 leads; with interpretation and report

93041 - Rhythm ECG, 1-3 leads; tracing only without interpretation and report

93042 - Rhythm ECG, 1-3 leads; interpretation and report only


ECG

The following is a summary of Current Procedural Terminology (procedure ®) codes commonly used for various electrocardiograph procedures performed with a Midmark ECG device. This information is provided only as a guide and is not intended to replace any official recommendations or guidelines, and does not constitute a promise or  guarantee by Midmark regarding coverage or payment. Always check with the specific payer for the appropriate use of any procedure  or ICD-10 codes. Physician fee schedule values listed are based on a national average and are rounded for brevity. Specific payments vary geographically. Codes and rates are subject to change. It is the responsibility of the provider to determine the correct coding for services provided.


procedure  Manual Instructions for Reporting Electrocardiographic Recording

• Codes 93040-93042 are appropriate when an order for the test is triggered by an event, the rhythm strip is used to help diagnose the presence or absence of an arrhythmia, and a report is generated.

• There must be a specific order for an electrocardiogram or rhythm strip followed by a separate, signed, written, and retrievable report.

• It is not appropriate to use these codes for reviewing telemetry monitor strips taken  from a monitoring system.

• The need for an electrocardiogram or rhythm strip should be supported by  documentation in the patient medical record.

Bundled Services per procedure  Manual:

• Do not report 93040-93042 when performing 93279-93289, 93291-93296, or  93298-93299

Report proper ICD-10-CM diagnosis codes to support the medical necessity for the use of an ECG.

ICD-10-CM codes and/or ranges are provided below to help with your decision process.


ICD-10-CM Description             ICD-10-CM Code/ Range

Abnormalities of heart beat R00.0-R00.9

Angina pectoris 120.0-120.9

Atherosclerotic heart disease I25.10-I25.119

Atrioventricular and left bundle-branch block 144.0-144.7

Cardiac arrest I46.2-I46.9

Cardiac murmurs and other cardiac sounds R01.0-R01.2

Cardiomyopathy I42.0-I42.9

Cardiomyopathy in diseases classified elsewhere I43

Essential (primary) hypertension I10

Gangrene, not elsewhere classified I96

Hypertensive heart disease I11.0-I11.9

Multiple valve diseases I08.0-I08.9

Old myocardial infarction I25.2

Other acute ischemic heart diseases I24.0-I24.9

Other cardiac arrhythmias I49.0-I49.9

Other conduction disorders I45.0-145.9

Other pulmonary heart diseases I27.0-I27.9

Pain in chest R07.1-R07.9

Rheumatic aortic valve diseases I06.0-I06.9

Rheumatic mitral valve diseases I05.0-I05.9

ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction I21.0-I21.4

Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction I22.0-I22.9


Usage With Modifier TC and 26

Billing Example – Procedure  93000

*Procedure  code 93000 has a PC/TC “4” indicator on MPFS Relative Value file

*Code described as global test only

*Modifier 26 or TC should not be appended to this procedure code


Billing Example – Procedure  93005

*Procedure  code 93005 has a PC/TC “3” indicator on MPFS Relative Value file

*Code described as technical component only

*Modifier 26 or TC should not be appended to this procedure code

Billing Example – Procedure  93010

*Procedure  code 93010 has a PC/TC “2” indicator on MPFS Relative Value file

*Code described as interpretation only

*Modifier 26 or TC should not be appended to this procedure code

Electrocardiography is a graphic record of electrical potentials produced by cardiac tissue. An electrographic tracing is created when electrical impulses produced by the heart spread to the body surface where they are detected by electrodes connected to a recording device. The ECG specifically addressed in this LCD is the standard 12-lead ECG, with or without a rhythm strip or other special leads. A qualified physician or NPP who is licensed by his state to perform these services must make an interpretation. The recording and interpretation should be part of the patient’s medical record.
The ECG is valuable in the evaluation and management of primary diseases of the heart, pericardium and coronary arteries. Electrocardiography may be useful in management of diseases that are not primarily cardiac but which frequently affect the heart either directly or indirectly. The following are indications for which the ECG is appropriate:

  • Cardiac ischemia or infarction (new symptoms or exacerbations of known disease).
  • Anatomic or structural abnormalities of the heart such as congenital, valvular or hypertrophic heart disease.
  • Rhythm disturbances and conduction system disease.
  • Chest and central nervous system trauma.
  • Use of medications or exposure to toxic substances that affect the heart.
  • Metabolic abnormalities such as hyper/hypokalemia, hyper/hypocalcemia, hyper/hypothyroidism, acidosis, alkalosis.
  • Systemic diseases that involve the heart.
  • Evaluation and management related to invasive cardiac procedures.
  • Evaluation of implanted electronic cardiac pacemakers.
  • Preoperative management of selected patients.
  • Patients with cardiac ischemia often present with chest pain. Not infrequently, patients with cardiac ischemia present with symptoms (including atypical chest discomfort) that are atypical for, but which may actually represent myocardial ischemia or infarction. The ECG may be utilized in the evaluation of patients with chest pain (typical or atypical) or other symptoms that are atypical but may be due to cardiac ischemia when an alternate explanation for the symptoms is not apparent.

Whereas there is no argument that the ECG is an important diagnostic tool, coverage cannot be provided for ECGs performed when there is no clear relationship to treatment or diagnosis of a specific disease or injury, or a sign, symptom or complaint is apparent. Payment for the services affected by this LCD must be made only for those services that directly contribute to the diagnosis and treatment of an individual patient. Services provided that do not directly contribute to the diagnosis or treatment of an individual patient (such as ECGs that are performed routinely upon admission to a facility or routinely performed prior to surgery) are not medically necessary and will be denied when billed and coded appropriately.

Preoperative electrocardiography is an important part of assessment of risk of preoperative cardiac morbidity. Important considerations include patient-specific predictors as well as surgery-specific risks. Medicare coverage of preoperative electrocardiography is limited to those patients who possess one or more patient-specific indicators of increased risk for perioperative cardiac morbidity and who will undergo surgery of high or intermediate risk of cardiac morbidity/mortality. Preoperative ECGs performed in circumstances other than those listed above are considered screening and should be billed accordingly.

Patient-specific predictors are such things as age, absence or presence of cardiac disease or dysfunction, current and recent stability of cardiac symptoms and syndromes, and the absence or presence of comorbid conditions known to increase the risk that undisclosed cardiac disease is present. Surgery-specific risks relate to the type of surgery and its associated degree of hemodynamic stress. High-risk procedures include major emergency surgery, aortic and major vascular surgeries, peripheral vascular surgery and prolonged procedures associated with large fluid shifts or blood loss. Intermediate-risk procedures include carotid endarterectomy, prostate surgery, orthopedic procedures, head and neck procedures, intraperitoneal and intrathoracic surgery. Low-risk procedures include endoscopy, superficial procedures, cataract surgery and breast surgery.
Medicare generally does not cover screening for heart disease. Though performance of a baseline ECG in certain asymptomatic patients is considered by many to be appropriate and standard medical practice, Medicare, by statute, may pay for such an ECG only as part of the one-time “Welcome to Medicare” preventative physical examination afforded by section 611 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. All other electrocardiography performed on asymptomatic individuals is considered screening regardless of the presence of risk factors (for cardiac disease) such as family history, hypertension, diabetes mellitus, hyperlipidemia or advanced age in circumstances where information obtained from the electrocardiogram does not directly affect management of the underlying disease.
Generally, one interpretation should be paid per ECG tracing. ECG interpretations (including “over-readings”) that are not made contemporaneous to patient care and/or that do not directly contribute to the diagnosis and treatment of the individual patient are not covered and should not be billed to Medicare. Examples of such non-covered over-reading services include those that are performed by a physician whether or not that physician is treating the patient in such a manner that the interpretation is unavailable to the treating physician timely for use in decision-making regarding patient care (i.e., interpretations of preoperative tracings that are not available to the surgeon prior to the procedure and interpretations of tracings performed during an Evaluation and Management (E/M) service prompted by acute symptoms that are not available until after the medical decision-making is complete).


 Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.



CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
93000©
Electrocardiogram, complete
93005©
Electrocardiogram, tracing
93010©
Electrocardiogram report


CPT CODE 93010 - EKG interpreation only


ECG and EKG billing and coding Guidelines

CPT code 93000 has a PC/TC “4” indicator on MPFS Relative Value file 
▪ Code described as global test only 

▪ Modifier 26 or TC should not be appended to this procedure code

CPT code 93005 has a PC/TC “3” indicator on MPFS Relative Value file 

▪ Code described as technical component only 

▪ Modifier 26 or TC should not be appended to this procedure code

▪ CPT code 93010 has a PC/TC “2” indicator on MPFS Relative Value file 
▪ Code described as interpretation only 

▪ Modifier 26 or TC should not be appended to this procedure code

Anthem Central Region bundles 93000, 93010, 93018, 93040, 93042 and 0180T as redundant/mutually exclusive to 99281-99285. Anthem considers interpretations of tests to be a component of performing the evaluation and management service. An ECG is performed while the patient is in the emergency department. The emergency physician performing his evaluation and management service interprets this ECG and makes a decision as to the type of treatment that is required for this patient. This interpretation is a component or part of the decision making portion of the evaluation and management services.

Anthem Central Region is following the Enterprise Reimbursement policy #0023 which reads: Separate reimbursement is not allowed for codes 93010, 93018, 93042 or 0180T when submitted with Emergency Room evaluation and management services on the same date of service. No modifier will override this Claim Edit.


An EKG will be considered medically necessary in any of the following circumstances:

1. Initial diagnostic workup for a patient that presents with complaints of symptoms such as chest pain, palpitations, dyspnea, dizziness, syncope, etc. which may suggest a cardiac origin.

2. Evaluation of a patient on a cardiac medication for a cardiac arrhythmia or other cardiac condition which affects the electrical conduction system of the heart ( e.g., inotropics such as digoxin; antiarrhythmics such as Tambocor, Procainamide, or Quinidine; and antianginals such as Cardizem, Isordil, Corgard, Procardia, Inderal and Verapamil). The EKG is necessary to evaluate the effect of the cardiac medication on the patient’s cardiac rhythm and/or conduction system.

3. Evaluation of a patient with a pacemaker with or without clinical findings (history or physical examination) that suggest possible pacemaker malfunction.

4. Evaluation of a patient who has a significant cardiac arrhythmia or conduction disorder in which an EKG is necessary as part of the evaluation and management of the patient. These disorders may include, but are not limited to, the following: Complete Heart Block, Second Degree AV Block, Left Bundle Branch Block, Right Bundle Branch Block, Paroxysmal VT, Atrial Fib/Flutter, Ventricular Fib/Flutter, Cardiac Arrest, Frequent PVCs, Frequent PACs, Wandering Atrial Pacemaker, and any other unspecified cardiac arrhythmia.

5. Evaluation of a patient with known Coronary Artery Disease (CAD) and/or heart muscle disease that presents with symptoms such as increasing shortness of breath (SOB), palpitations, angina, etc.

6. Evaluation of a patient’s response to a newly established therapy for angina, palpitations, arrhythmias, SOB or other cardiopulmonary disease process.

7. Evaluation of patients after coronary artery revascularization by Coronary Artery Bypass Grafting (CABGs), Percutaneous Transluminal Coronary Angiography (PTCA), thrombolytic therapy (e.g., TPA, Streptokinase, Urokinase), and/or stent placement.

8. Evaluation of patients presenting with symptoms of a Myocardial Infarction (MI).

9. Evaluation of other symptomatology which may indicate a cardiac origin especially in those patients who have a history of an MI, CABG surgery or PTCA or patients who are being treated medically after a positive stress test or cardiac catherization.

10. Pre-operative Evaluation of the patient when:

- undergoing cardiac surgery such as CABGs, automatic implantable cardiac defibrillator, or pacemaker, or 

- the patient has a medical condition associated with a significant risk of serious cardiac arrhythmia and/or myocardial ischemia such as Diabetes, history of MI, angina pectoris, aneurysm of heart wall, chronic ischemic heart disease, pericarditis, valvular disease or cardiomyopathy to name a few.

11. Evaluation of a patient’s response to the administration of an agent known to result in cardiac or EKG abnormalities (for patients with suspected, or at increased risk of developing, cardiovascular disease or dysfunction). Examples of these agents are antineoplastic drugs, lithium, tranquilizers, anticonvulsants, and antidepressant agents.


12. When performed as a baseline evaluation prior to the initiation of an agent known to result in cardiac or EKG abnormalities. An example of such an agent is verapamil.


Edit

93005 (Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report) and (Rhythm ECG, one to three leads; tracing only without interpretation and report) bundles with A0426 (Ambulance service, advanced life support, non-emergency transport, level I {ALS}), A0427 (Ambulance service, advanced life support, emergency transport, level I {ALS I-emergency}), A0428 (Ambulance service, basic life support, non-emergency transport {BLS}), A0429 (Ambulance service, basic life support, emergency transport {BLS-emergency}), A0430 (Ambulance service, conventional air services, transport, one way {fixed wing}), A0431 (Ambulance service, conventional air services, transport, one way {rotary wing}), A0432 (Paramedic intercept {PI}, rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers), A0433 (Advanced life support, level 2 {ALS 2}), A0434 (Specialty care transport {SCT}), A0800 (Ambulance transport provided between the hours of 7 p.m. and 7 a.m.), and A0999 (Unlisted ambulance service).


93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report), 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only), 93040 (Rhythm ECG, one to three leads; with interpretation and report) and 93042 (Rhythm ECG, one to three leads; interpretation and report only) bundles with A0426 (Ambulance service, advanced life support, nonemergency transport, level I {ALS}), A0427 (Ambulance service, advanced life support, emergency transport, level I {ALS I-emergency}), A0428 (Ambulance service, basic life support, non-emergency transport {BLS}), A0429 (Ambulance service, basic life support, emergency transport {BLSemergency}), A0430 (Ambulance service, conventional air services, transport, one way {fixed wing}), A0431 (Ambulance service, conventional air services, transport, one way {rotary wing}), A0432 (Paramedic intercept {PI}, rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers), A0433 (Advanced life support, level 2 {ALS 2}), A0434 (Specialty care transport {SCT}), A0800 (Ambulance transport provided between the hours of 7 p.m. and 7 a.m.), and A0999 (Unlisted ambulance service). 




Description

An electrocardiogram is a graphic tracing of the variation in electrical potential caused by the excitation of the heart muscle and detected at the body surface. The normal electrocardiogram shows deflections resulting from atrial and ventricular activity. The first deflection, P, is due to excitation of the atria. The QRS deflections are due to excitation (depolarization) of the ventricles.

The T wave is due to recovery of the ventricles (repolarization). The U wave is a potential undulation of unknown origin immediately following the T wave, seen in normal electrocardiograms and accentuated in hypokalemia. It is abbreviated ECG or EKG. The ECG tracing shows changes in magnitude of voltage and polarity (positive and negative) with time.

In the inpatient and outpatient hospital and emergency room settings, billing for ECGs may be divided into a technical component (performing the ECG) and a professional component (interpretation and report of the ECG).'


Principles

1. BCBSNC only reimburses providers for services delivered directly to the member or to the management of a member’s condition. Consistent with Medicare guidelines, interpretation of the ECG must be done contemporaneously (at the time that clinical management decisions are being made).

2. BCBSNC will reimburse for interpretation of the ECG once, except under unusual consultative circumstances. The interpretation or the fee for the interpretation should be submitted based on place of service where the ECG was performed.

3. BCBSNC reimbursement for the professional component (procedure  93010) is for "interpretation and report" of an ECG procedure, not "review" of the procedure. A review of the findings of these procedures, without a written report, does not meet the conditions for separate payment of the service since the review is already included in the emergency room visit payment.

4. “Global only” codes represent a routine ECG with at least 12 leads and include the physician’s interpretation and report. Other procedure  codes are established to specify the “technical” component, (the ECG tracing only), and the “professional” component (for interpretation and report only). It is not appropriate to use modifiers -26 or –TC with these latter codes.

5. When Rhythm ECG, interpretation and report only, is billed the same date as an Evaluation and Management service in the hospital setting, then the rhythm ECG will be denied as a component  f the Evaluation and Management service. 

ECG Reimbursement

Blue Cross and Blue Shield of North Carolina’s Criteria for Reimbursement of Professional Interpretation of ECGs Physicians may be eligible for professional reimbursement of ECG interpretation (procedure  93010) when ALL of the following criteria are met:

1. Based on information obtained from the hospital and provider, BCBSNC will determine which providers are eligible for reimbursement for the professional component of ECGs performed in the emergency room. AND

2. The medical record supports the provider assertion that the ECG reports document independent reimbursable services, including ALL of the following:

a) The ECG is used to diagnose and/or manage an ER patient’s condition acutely.

b) The report is identifiable as a separate report (either a separate document or a clearly identifiable and independent portion of the ER record).

c) The report contains ALL components of a full 12 lead ECG report, including:

i. Name of patient

ii. Date of patient’s birth and age

iii. Patient identification number

iv. Ordering physician’s name

v. Date the technical portion of the study was performed

vi. Full and permanent graphical representation including I, II, III, aVL, aVR, aVF, and V1-V6, and rhythm strip.

vii. Measurement of all intervals (PR, QRS, QT) and axis.

viii. Documentation of rhythm and heart rate.

ix. Interpretation of the ECG tracing by the billing provider.

x. Legible signature by interpreting provider and date of interpretation noted independently of the ER record.

Please note: In light of the recent advances in information technology, specifically the development of electronic health records (EHR), BCBSNC will accept documentation of the above criteria in EHR format. This includes the physician’s  interpretation and electronic signature  Policy Guidelines

BCBSNC may request medical records for determination of correct coding. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to ensure correct coding is included.'

Documentation Requirements
  • Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
  • Documentation should demonstrate that services are provided according to all requirements of this LCD. In this respect, the record should demonstrate the following:
    • Evidence of recent, past, ongoing or suspected cardiac disease or symptoms.
    • For patients in whom the ECG is performed as part of the evaluation of chest pain or symptoms that are atypical for cardiac ischemia, the record must substantiate that the ordering clinician has a valid concern that the etiology of the chest pain or other symptoms is cardiac in origin. Conversely, the record may show that the ECG is being used to exclude cardiac origin for symptoms (including chest pain) for which cardiac origin cannot be excluded by history or physical examination.
    • For serial ECGs, information supporting the medical necessity for repeating the studies at the given interval should be present. Sequential ECGs, either short-term for an acute condition or long-term for a chronic condition, are often appropriate. Documentation must demonstrate that the findings of the test affect management of the condition.
    • The report of the professional component (the interpretation) for the ECG must be a complete written report that includes relevant findings and appropriate comparisons. The interpretation may appear on the actual tracing or with a progress note or other report of an E/M service when the ECG is performed in conjunction with performance of an E/M service. An interpretation reported in the latter fashion, when billed as a separate service from the E/M service, should contain the same information as a report made upon the tracing itself. A simple notation of “ECG/EKG normal,” without accompanying tracing, will not, in this circumstance, suffice as documentation of a separately payable interpretation.
    • Preoperative ECG studies must indicate the underlying cardiac condition or risks, as well as the proposed operation for which cardiac evaluation is being performed. The ECG must be performed reasonably proximate to the proposed surgery to be considered medically necessary.

EKG Interpretations

For services provided between January 1, 1992, and December 31, 1993, carriers must not make separate payment for EKG interpretations performed or ordered as part of, or in conjunction with, visit or consultation services. The EKG interpretation codes that are bundled in this way are 93000, 93010, 93040, and 93042. Virtually, all EKGs are performed as part of or ordered in conjunction with a visit, including a hospital visit. 

If the global code is billed for, i.e., codes 93000 or 93040, carriers should assume that the EKG interpretation was performed or ordered as part of a visit or consultation.

Therefore, they make separate payment for the tracing only portion of the service, i.e., code 93005 for 93000 and code 93041 for 93040. When the carrier makes this assumption in processing a claim, they include a message to that effect on the Medicare Summary Notice (MSN). 

For services provided on or after January 1, 1994, carriers make separate payment for an EKG interpretation. 

3 comments:

Nikki said...

Very useful information...

Medicare Delaware

Anonymous said...

What is the source for this content? I see no sources listed?

Anonymous said...

I am looking for the current NCD/LCD policy for this. All I can find on CMS is a retired policy. Can you help? I am in KS
Thank you!

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