LCD L34315

Coverage Guidance

Title XVIII of the Social Security Act (SSA), §1862(a)(1)(A), states that no Medicare payment shall be made for items or services that "are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member."

Title XVIII of the Social Security Act, §1862(a)(7) and 42 Code of Federal Regulations, §411.15, exclude routine physical examinations.

Title XVIII of the Social Security Act, §1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.

Medicare's Carrier's Manual (MCM), §15047(D), explains coverage for preoperative diagnostic tests performed to determine a patient's perioperative risks and optimize perioperative care. (The reference will be crosswalked to the CMS Manual System, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, §30.6.6.1 as soon as it become available.)

Medicare Carriers Manual, §15047(G), explains how to report preoperative tests. (The reference will be crosswalked to the CMS Manual System, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, §30.6.6.1 as soon as it becomes available.)

CMS Manual System, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, §20.3(E), describes bundling of payment for ECG services supplied concomitantly with other physician services.

CMS Manual System, Publication 100-04, Medicare Claims Processing Manual, Chapter 13, §100.1, states that in general only one payment is made for one interpretation of an EKG.

CMS Manual System, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, §20.9.1. Correct Coding Initiative (CCI) describes correct usage of the 59 modifier for repeat procedural services performed on the same day.

CMS Manual System, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, §20.15, Electrocardiogram Service, "No payment is made for EKG interpretations by individuals other than physicians' and "A separate charge by an attending or consulting physician for EKG interpretation is allowed only when it is the normal practice to make such charge".

CMS Manual System, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, §§190 and 200, allow for services supplied by physician assistants and nurse practitioners.

CMS Manual System, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, §250, states that payment may be made under Part B for the medical and other health services enumerated in paragraph C, but only where no payment can be made for such services under Part A.

Indications and Limitations of Coverage

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.

Summary of Evidence

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Analysis of Evidence

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Associated Information

No comments were received for this draft LCD for comment period ending 08/14/2017.

Bibliography

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