ECG Reimbursement

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).

Policy

1. Blue Cross Blue Shield North Carolina (Blue Cross NC) 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. Blue Cross NC 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. Blue Cross NC reimbursement for the professional component (CPT® 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 CPT 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 of the Evaluation and Management service. 

Reimbursement Guidelines

Physicians may be eligible for professional reimbursement of ECG interpretation (CPT® 93010) when ALL of the following criteria are met:

1. The medical record supports the provider assertion that the ECG reports document independent reimbursable services, including ALL of the following:
   1. The ECG is used to diagnose and/or manage an ER patient’s condition acutely.
   2. The report is identifiable as a separate report (either a separate document or a clearly identifiable and independent portion of the ER record).
   3. The report contains ALL components of a full 12 lead ECG report, including:
      1. Name of patient
      2. Date of patient’s birth and age
      3. Patient identification number
      4. Ordering physician’s name
      5. Date the technical portion of the study was performed
      6. Full and permanent graphical representation including I, II, III, aVL, aVR, aVF, and V1-V6, and rhythm strip.
      7. Measurement of all intervals (PR, QRS, QT) and axis.
      8. Documentation of rhythm and heart rate.
      9. Interpretation of the ECG tracing by the billing provider.
      10. 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.

Rationale

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. 

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at Blue Cross NC.

Related policy

Bundling Guidelines

References

Federal Register. Rules and Regulations. X95-11208.pdf (govinfo.gov).

Medical Policy Advisory Group – 10/2003

Medical Policy Advisory Group – 03/10/2005

Medical Policy Advisory Group – 03/24/2006

Senior Medical Director review 4/2011

Medical Director review 01/2012

Medical Director review 11/2013

Medical Director review 3/2015

History

8/03 Original policy issued.

10/03 Medical Policy Advisory Group review. No changes to policy. Reaffirm.

02/05 Added the following statement to the Principles section of the policy. “The interpretation or the fee for the interpretation should be submitted based on place of service where the ECG was performed.

04/07/05 Medical Policy Advisory Group reviewed policy on 03/10/2005. Typos corrected.

5/08/06 Medical Policy Advisory Group review 3/24/06. No change to policy criteria. Policy number added to the Key Words Section.

3/26/07 Medical Policy reviewed by Senior Medical Director of Network Support.

05/05/08 No changes to policy criteria. Policy reviewed 04/04/2008 by Vice President and Senior Medical Director of Provider Partnerships, Medical and Reimbursement Policy. Policy status changed to “Active policy, no longer scheduled for routine literature review.”

6/22/10 Policy Number(s) removed (amw)

4/26/11 Added the following statements to the “Criteria for Reimbursement” section: “Please note: In light of the recent advances in information technology, specifically the development of electronic health records (AND), BCBSNC will accept documentation of the above criteria in AND format. This includes the physician’s interpretation and electronic signature.” (mco)

3/6/12 Policy returned to “active review” status. The following was added to the Principles section Item 4. “Global only” codes represent a routine ECG with at least 12 leads and include the physician’s interpretation and report. Other CPT 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. Item 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 of the Evaluation and Management service. (and)

12/10/13 Routine policy review. Name of policy changed from “ECG Reimbursement Issues” to “ECG Reimbursement.” (and)

5/13/14 Policy category changed from “Corporate Medical Policy” to “Corporate Reimbursement Policy”. No changes to policy content. (and)

4/28/15 Routine policy review. Revised wording in Policy Guidelines section. Medical records may be requested for determination of correct coding. Otherwise, no changes to policy content. (and)

12/30/16 Routine policy review. No change to policy statement. (an)

12/29/17 Routine policy review. No change to policy statement. (an)

12/14/18 Routine policy review. No change to policy statement. (an)

3/12/19 The following statement was deleted from the section titled “Criteria for Reimbursement of Professional Interpretation of ECGs”: 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. (an)

1/14/20 Routine policy review. Senior Medical Director approved 12/2019. No changes to policy statement. (an)

12/31/20 Routine policy review. Medical Director approved 12/2020. No changes to policy statement. (eel)

4/20/21 Policy format update. No changes to policy statement.  (eel)  

12/30/21 Routine policy review. Medical Director approved. (eel)

12/31/2022 Routine policy review. Minor revisions only. (ckb)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.