Does Medicare Pay for an Electrocardiogram (EKG)?

An electrocardiogram (EKG) is a non-invasive diagnostic tool that assesses the heart’s electrical activity. This test helps healthcare providers identify various heart conditions, such as arrhythmias or signs of a heart attack. Many individuals depend on Medicare for healthcare expenses, leading to questions about EKG coverage. Understanding how Medicare addresses EKG costs is important for beneficiaries navigating their health benefits.

Medicare Coverage for Electrocardiograms

Medicare covers electrocardiograms through specific parts of its program. Medicare Part B, medical insurance, is the primary component covering outpatient diagnostic tests, including EKGs. This coverage applies when the test is performed in a doctor’s office, clinic, or an outpatient hospital department.

EKGs may also fall under Medicare Part A, hospital insurance, if the test is administered during an inpatient hospital stay. Medicare Advantage Plans (Part C) cover EKG services, as these plans are required to provide at least the same level of coverage as Original Medicare (Parts A and B). Medicare Part D does not cover EKG services.

When Medicare Covers an EKG

Medicare covers an EKG when a healthcare provider determines it is medically necessary to diagnose or treat a medical condition. Situations warranting a medically necessary EKG include evaluating symptoms like chest pain, shortness of breath, or an irregular heartbeat. The test can also be covered for monitoring known heart conditions or assessing a patient before certain procedures.

While diagnostic EKGs are covered when medically necessary, coverage for screening EKGs is more limited. A one-time EKG screening is covered if it is part of the “Welcome to Medicare” preventive visit, available within the first 12 months of enrolling in Medicare. Beyond this initial visit, routine or screening EKGs are not covered unless specific risk factors or documented symptoms justify the test. EKGs performed as part of a routine physical exam, separate from the “Welcome to Medicare” visit or an Annual Wellness Visit, are not covered.

Your Share of EKG Costs

When Medicare Part B covers an EKG, beneficiaries have out-of-pocket costs. After meeting the annual Part B deductible, Medicare pays 80% of the Medicare-approved amount for the EKG. The beneficiary is responsible for the remaining 20% coinsurance. For example, if the Medicare-approved amount is $100 and the deductible has been met, Medicare pays $80, and the beneficiary pays $20.

Costs can vary based on the setting where the EKG is performed. If the test occurs in a hospital outpatient department, an additional hospital copayment may apply on top of the 20% coinsurance. Medicare Advantage plans may have different cost-sharing structures, such as copayments or coinsurance, but they must cover medically necessary EKGs. These plans may also require beneficiaries to use in-network providers. Medicare Supplement Insurance policies, known as Medigap, can help cover the 20% coinsurance and potentially the Part B deductible, reducing out-of-pocket expenses.

Working with Providers and Bills

Ensuring proper coverage and billing for an EKG involves proactive steps. Confirm that the healthcare provider and facility accept Medicare assignment, meaning they agree to accept the Medicare-approved amount as full payment. Before the service, discuss with your doctor the medical necessity for the EKG, ensuring it is clearly documented in your medical record. This documentation is crucial for Medicare to process the claim.

After receiving services, review your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) if you have a Medicare Advantage plan. The MSN, sent every three to four months, details the services billed to Medicare, the amount Medicare paid, and the amount you may owe. If questions arise about a bill or a service appears incorrectly denied, first contact your provider’s billing department. If issues persist, Medicare provides an appeals process to challenge coverage decisions.