Electrocardiogram, tracing only, CPT® 93005 - Targeted Probe and Educate Review Results - JF Part B

In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs pre-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.

This is to update providers of the claim review findings for 93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report. The results of this focused review are not a reflection on providers' competence as a health care professional or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility's compliance with the required documentation.

The Jurisdiction F, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 93005 – Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report. The quarterly edit effectiveness results from October 1, 2023, through December 31, 2023, are as follows:

Top Denial Reasons

• Failure to return records.
• The documentation submitted was incomplete and/or insufficient.

Educational Resources

• How to respond to an ADR
• Documentation Guidelines for Medicare Services
• Local Coverage Determination (LCD) L37283 Electrocardiograms

Education

Failure To Return Records

The Internet-Only Manual (IOM) addresses timeframes for submission of records for pre-payment reviews in the Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.2.
"When requesting documentation for prepayment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46."

Incomplete And/Or Insufficient Documentation

When additional documentation has been requested to verify compliance with the CPT® code billed and the submitted documentation lacks evidence to support that, the claim will be denied as the documentation submitted was incomplete and/or insufficient. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8(C).

Electrocardiogram 12 leads tracing only, CPT® 93005

Multiple electrodes are placed on a patient's chest to record the electrical activity of the heart. A physician interprets the findings. The documentation must support the supervising physician as the rendering physician.

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.