An electrocardiogram, commonly known by its initials EKG or ECG, is a non-invasive diagnostic tool used to measure the electrical activity of the heart. This test involves placing electrodes on the skin to record the electrical impulses that control the heart’s rhythm, providing information about heart rate, the strength and timing of signals, and potential damage from a heart attack or other conditions. Medicare generally covers this procedure, but only when a healthcare provider determines it is medically necessary to diagnose or treat a health condition. Coverage is also provided for a one-time screening EKG during the “Welcome to Medicare” preventive visit, which must occur within the first 12 months of Part B enrollment.
Coverage Based on Care Setting
The location where the EKG is performed determines which part of Original Medicare pays for the service, which in turn affects the patient’s financial responsibility. Most EKGs are conducted in an outpatient setting, such as a doctor’s office or an independent clinic. In these common scenarios, the service is covered under Medicare Part B, which addresses medical services outside of inpatient hospital stays.
If the EKG is performed while a patient is formally admitted to a hospital, it falls under Medicare Part A, which covers inpatient hospital care. In this case, the test is bundled into the overall hospital stay costs, which are subject to the Part A deductible.
Standard Patient Costs Under Original Medicare
For an EKG performed in an outpatient setting and covered by Original Medicare Part B, the patient’s out-of-pocket cost follows a two-step process. First, the patient must have met their annual Part B deductible. After this deductible is satisfied, Medicare pays for 80% of the Medicare-approved amount for the EKG.
The remaining 20% of the Medicare-approved amount is the patient’s coinsurance responsibility. For instance, if the Medicare-approved amount for a particular EKG is $100, Medicare pays $80, and the patient pays the remaining $20.
If the EKG is done in a hospital outpatient department, the patient may also be charged a separate hospital copayment in addition to the 20% Part B coinsurance. If the test is performed during a qualifying inpatient stay, the cost is covered under the Part A hospital deductible, meaning the patient typically pays nothing extra for the EKG itself.
How Supplemental Plans Change Financial Responsibility
Many beneficiaries choose to enroll in a plan beyond Original Medicare to reduce their out-of-pocket expenses. Medicare Advantage plans are offered by private insurance companies and must cover all the services of Original Medicare, including medically necessary EKGs. However, Part C plans use different cost-sharing rules, often substituting the 20% coinsurance with a fixed copayment.
The exact copayment for an EKG under a Medicare Advantage plan varies significantly based on the specific plan’s structure. A patient might have a low fixed copay, such as $10 or $20, for a diagnostic test. It is necessary to review the plan’s summary of benefits to determine the specific copay for diagnostic services.
Alternatively, a Medigap policy is supplemental insurance that works alongside Original Medicare. These plans are designed to cover the “gaps” in Original Medicare, such as the Part B 20% coinsurance. Depending on the specific Medigap plan letter chosen, the policy can pay the entire 20% coinsurance, potentially reducing the patient’s out-of-pocket cost for the EKG to zero.
Variables That Determine the Total Cost
The total cost of an EKG can fluctuate based on several factors. One significant variable is the setting where the test is conducted. An EKG performed in a hospital outpatient department usually carries a higher facility fee compared to the same test administered in a physician’s private office.
Geographic location also plays a role, with the costs for medical services varying across different regions of the country. The Medicare-approved amount, which is the maximum amount Medicare will pay for a service, is calculated based on these factors. This approved amount directly dictates the size of the 20% coinsurance the patient pays.
A third variable is the provider’s “assignment status,” which refers to whether the doctor agrees to accept the Medicare-approved amount as full payment. If a provider does not accept assignment, they are permitted to charge the patient up to 15% more than the Medicare-approved amount. This extra charge, known as balance billing, is the patient’s responsibility and can increase the total out-of-pocket cost.