Did you know that among the G20 countries, the United States ranks third when it comes to the prevalence of cardiovascular disease (CVD). According to the American Heart Association, 127.9 million U.S. adults (48.6%) had some form of CVD between 2017 and 2020. Unfortunately, CVD is the leading cause of death in the USA, making up 39.5% of all deaths in the country.
However, early diagnosis and treatment can prevent fatalities. 12-lead electrocardiography, represented by CPT code 93005, is the most widely used cardiovascular procedure to diagnose CVD. Over 100 million ECGs are obtained in the U.S. each year. So, let’s comprehend the ins and outs of CPT code 93005 since, at cardiology practices, this is where the real revenue opportunity lies.
CPT Code 93005 – Description
The Current Procedural Terminology (CPT) code 93005 is under the ‘Cardiography Procedures’ code range, as maintained by the American Medical Association (AMA). Healthcare providers must use this cardiology CPT code for billing when they perform a routine 12-lead electrocardiogram (ECG/EKG) to record the heart’s electrical activity for 10-15 minutes. The code only represents the tracing portion of the procedure without results interpretation or report preparation.
If the code’s descriptor is still somewhat unclear, let us explain how an electrocardiography is performed so you know exactly when to apply this code for billing and reimbursement.
An ECG machine captures the electrical signals emitted by the heart. These signals are visible as waves on the monitor/screen. The recorded results can also be printed on paper in real-time. A 12-channel ECG has 12 electrodes, which are placed on different parts of the body to monitor the heart’s function comprehensively. Cardiologists often rely on this multilead approach to diagnose various heart conditions, such as weakened heart muscle, abnormal heartbeats, and coronary artery disease.
Unlike stress tests, CPT code 93005 is for recording the heart’s electrical activity when the patient is lying down on a bed and connected to an ECG machine for up to 15 minutes. Also, this non-invasive diagnostic test is performed without sedation (anesthesia administration).
Appropriate Use Cases for CPT Code 93005
A 12-lead ECG is one of the most common tests for diagnosing cardiovascular disease. It is also the most frequently ordered cardiac test. Represented by CPT code 93005, a 12-channel ECG is performed on patients exhibiting symptoms like chest pain, palpitations, and shortness of breath (dyspnea). It may even be performed on asymptomatic patients for cardiovascular disease management or as a routine screening.
Let’s discuss three possible clinical scenarios in detail, which would require the cardiologist to perform a 12-lead ECG and report it with CPT code 93005.
Diagnosing Cardiac Arrhythmias
Imagine that a 68-year-old woman visits the hospital complaining of chest pain, slow heartbeat, and extreme tiredness. The physician checks her vitals and records a heart rate of 55 beats per minute. Upon further probing, the patient reveals a family history of cardiovascular disease.
The physician refers her to the cardiology unit, where she is asked to undergo a 12-lead electrocardiogram (CPT code 93005) to rule out or confirm bradycardia or slow heartbeat (a type of heart arrhythmia). Note that as the physician did not interpret or document the results, code 93005 is accurately applicable to the situation.
Detecting Conduction System Abnormalities
Suppose that a 50-year-old obese woman with a family history of cardiovascular disease is undergoing a routine 12-lead ECG (CPT code 93005). She is asymptomatic but often experiences high blood pressure (hypertension).
During the ECG, the physician notices an abnormal heart rhythm. He notices that there is a delay in the electrical signals, because of which the right ventricle contracts later than the left ventricle. Whereas in normal circumstances, both ventricles must contract simultaneously. Therefore, the patient is diagnosed with right bundle branch block (RBBB), which is a heart conduction disorder affecting around 0.8% of people aged 50 and above.
Note that CPT code 93005 will only be used for ECG tracing. For the second part of the procedure, which involves interpreting the ECG results, detecting RBBB, and documenting the results, CPT code 93010 will be used.
Confirming Suspected Acute Coronary Syndrome
Consider a 40-year-old diabetic woman with hypertension who visits the physician’s office complaining of chest pain, shortness of breath, and sudden/heavy sweating. During physical examination, the physician notices that the woman is overweight. He suspects the patient to be experiencing acute coronary syndrome (ACS). To confirm or rule out his suspicion, the physician orders a resting 12-lead ECG tracing (CPT code 93005).
Modifiers to Append with CPT Code 93005
The following modifiers are typically appended to CPT code 93005 to highlight the special circumstances in which a resting 12-lead electrocardiogram was performed.
Modifier 59
If another service was performed on the same day as a 12-lead ECG, modifier 59 should be appended to CPT code 93005 to indicate that the two services are distinct and separately payable. Modifier 59 helps providers avoid denials that arise from speculated claim duplications.
In simple terms, it signifies that although the first service and a 12-lead ECG are not typically reported together, both were medically necessary and deserve separate reimbursements.
Modifier 76
There may be instances when it becomes medically necessary to track changes in the heart’s electrical activity over time. In this case, modifier 76 is appended to CPT code 93005 to explain to the payer that the same healthcare provider performed a subsequent 12-lead ECG on the same day. Modifier 76 also helps prevent duplicate claim denials when procedures are repeated for medical reasons.
Modifier 77
In contrast, modifier 77 explains that another healthcare provider repeated the 12-lead ECG on the same day to obtain subsequent results.
Reimbursement Guidelines for CPT Code 93005
Insurance claims for ECGs are often denied due to common billing mistakes, such as incorrect code selection or missing documentation. After considering the most frequently reported denial reasons for claims with CPT code 93005, we have come up with a few billing tips to help you file error-free claims. Let’s discuss them in detail so you can collect fair reimbursements on time.
Do Not Confuse 93005 with Other ECG Codes
CPT code 93005 only covers electrocardiogram tracing. Therefore, you can only use this code if the provider performed a 12-lead ECG (while the patient was at rest) without interpreting the results or reporting them. However, if he performed a comprehensive 12-lead ECG, which included tracing of the heart’s electrical activity, interpretation of the results, and reporting of the findings, then CPT code 93000 should be used instead.
Attach Supporting Documentation
Detailed and accurate documentation must be provided with the claim form to support the medical necessity of a routine 12-lead electrocardiogram (CPT code 93005). You must note that Medicare Part B only covers a routine ECG once for screening purposes if a physician referred the patient for a “Welcome to Medicare” preventative visit. Otherwise, only diagnostic ECGs are covered if the physician provides sufficient proof of medical necessity.
Therefore, your documentation should include:
- The patient’s complete medical record
- Accurate patient identification information (complete name, service dates, date of birth, etc.)
- The physician’s or non-physician practitioner’s legible signature on the documents
- Clinical notes describing the patient’s condition and symptoms
- Printouts of ECG tracing
- Referral letters, if any
Pair with the Appropriate ICD-10-CM Code
You must also pair CPT code 93005 with the most appropriate ICD-10-CM codes to establish the medical necessity of a 12-lead ECG. Medicare provides a complete list of ICD-10-CM codes that can be paired with 93005 for successful claim processing and reimbursement collection. Some of these are as follows:
- I24.81 – Acute coronary microvascular dysfunction
- I25.110 – Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
- I25.3 – Aneurysm of the heart
- I25.41 – Coronary artery aneurysm
- R00.0 – Tachycardia, unspecified
- R00.1 – Bradycardia, unspecified
- R01.1 – Cardiac murmur, unspecified
- R06.02 – Shortness of breath
- R06.82 – Tachypnea, not elsewhere classified
- R07.1 – Chest pain on breathing
Refer to the Relevant Payer’s Policy Manuals
Billing guidelines and reimbursement policies vary across payers. Both government payers (Medicare and Medicaid) and commercial payers have their specific rules and regulations for coding and billing cardiography procedures. So, before reporting one unit of CPT code 93005, review the National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and commercial payers’ policy manuals to ensure clean and compliant claim submission.
Final Thoughts on CPT Code 93005
CPT code 93005 is one of the most reported procedural codes in cardiology. It represents a routine 12-lead electrocardiogram tracing without interpretation and reporting. Now, one may think that because of its frequent use in insurance billing, medical billers must be getting it right every time and collecting decent payments against it, but the on-ground reality is quite different.
From incorrect code selection and missing modifiers to documentation gaps and coverage issues, several billing mistakes trigger denials. We have tried to cover key information on CPT code 93005 to improve your clean claim submission rate. However, if you are still apprehensive about ECG billing, consider professional cardiology billing services from experts at NeuraBill and let them handle the intricacies.
