Technology Update - EKG Analysis
Gresham Bayne MD

The most common "technology" question coursing through the AAHCP ListServe these days is "What type of EKG machine do you use?" The use of EKG in home care for physicians provides a simple, portable documentation of both the rhythm strip and, if necessary, a full 12-lead EKG. Some devices allow for one-touch visualization of the rhythm strip with memory capture for remote print-out but no 12-lead. Since the rhythm strip is often bundled into any E/M service rendered that date (even if at a different time), and the removal of the transportation fee for EKG lowers reimbursement to about $24 for both technical and professional components, it is important to analyze the purchase of such machines carefully.

The use of an EKG machine in the office setting with the occasional housecall may lead to a different choice of machine than one for housecalls alone. An office setting allows much higher potential volume of testing and places less imphasis on size and weight than the mobile doctor setting. In the mobile setting, additional factors such as print options, battery life, storage capacity, and heated stylus printing methodology become important. I started doing EKGs on housecalls in 1985 and found the only version available then used a 9-volt battery you could buy anywhere (good) and a heated stylus printer to paper which oxidized quickly in the sun (bad).To make the right choice, an EKG machine must ultimately provide a hard printed record and not lose money, so an analysis with certain assumptions can help prevent "buyer's remorse."

Once you have defined the form and function of the machine you would like, the physician should analyze the total cost of use. For example, a physician plans to make housecalls full time, and estimates that an EKG will be required every 20th housecall. The useful life of the $3,000 machine selected is estimated to be 5 years on an amotization schedule and the per test use of electrodes and printing paper is $2.50. Her bad debt collections is 10% under Medicare assignment, and it costs a further 10% for billings and collections for her practice. If this physician averages 7 housecalls (HC) daily after vacations and CME time off is taken into account and works a five day week (22-day month), she can calculate the profitability of an EKG machine as follows:

If:

1. Medicare allowed charges for your area are $24 per EKG (revenue)
2. 7 x 22 x 10% = #EKGs/mo
3. ($2.50 x #EKGs/mo) = direct cost/mo
4. $3000/60mo + ($24 x .10 x #EKGs/mo) = indirect cost/mo

It seems clear that no one is getting rich using an EKG on housecalls, but other factors might affect the decision to upgrade your service and which machine to choose. The Level IV established patient visit requires moderate to high complexity, which requires the interpretation of lab or XRay generally. Having an EKG reading available may allow compliant billing at Level IV not to mention the importance a tracing might have on the quality of care and the ability to avoid a trip to the emergency room.

Given this type of analysis, adjusted for the physician's practice style, desires and realities, there are a number of machines to choose from. Below are the names and websites of EKG machines with which I am familiar, and some notes about each. For the 12-lead capability you can expect to pay around $3,000 or more. For the rhythm strip-only devices, costs are much less.

• CM 4000 (www.ttiac.com): most convenient; has one-touch with screen capability, 12-lead with harness, light and fits in the "black bag"
• PC-EKG (www.brentwoodmed.com): the most advanced lightweight fax and email enabled EKG used easily with any portable computer
• Shiller AT-1 (www.welchallyn.com): takes EKG and prints in the home on same device; heavy and bulky but print-out looks like a hospital printout
• Burdick Spacelab Elite II (www.burdick.com): similar to Shiller; unfortunately the old Burdick of the 1980s (the best I have ever used) has been discontinued.
• ActiveEKG (www.activecenter.com): under $500 and works with a handheld Palm; rhythm strip only