What documentation supports a CPT code for an ECG?

• A. 12-lead ECG performed with no interpretation
• B. 12-lead ECG performed with interpretation but no date/time
• C. ECG only order
• D. 12-lead ECG performed with interpretation and the date/time

Answer: (D)

The essential documentation for billing an ECG is that the actual 12-lead tracing was performed, there is a clinician’s interpretation with a written report, and the date/time of service is recorded. This combination demonstrates that the test was carried out, interpreted, and documented at a specific time, which is what CPT billing requires for the professional component. The option that includes the 12-lead ECG performed with interpretation and the date/time provides all of these elements, making it the best choice. Without interpretation, you don’t have the diagnostic input needed for the claim; without the date/time, you can’t establish when the service occurred; and an ECG order alone does not prove that the test was performed or interpreted.