Cardiovascular stress testing is a core diagnostic tool for evaluating ischemia, chest pain, shortness of breath, arrhythmias, and exercise capacity. Because a stress test can involve multiple participants—such as a facility performing the test, a clinician supervising it, and a cardiologist interpreting the results—each party bills for the portion of work they perform.
CPT 93018 is used specifically for the interpretation and reporting of a cardiovascular stress test. Strengthen compliance for TTE procedures using our detailed CPT 93306 Transthoracic Echocardiogram Billing Guide featuring documentation tips, supervision rules, and NCCI guidance.
This guide explains exactly when to use CPT 93018, what documentation is required, payer rules, prior authorization requirements, and how to avoid common denials.
What Is CPT 93018?
The CPT manual defines 93018 as:
“Cardiovascular stress test… interpretation and report only.”
In practical clinical terms:
CPT 93018 = the Cardiologist’s interpretation of the stress test plus the final diagnostic report.
This code is billed when you:
- Review the ECG tracings
- Analyze the patient’s physiologic response
- Evaluate symptoms and hemodynamics
- Assess for ischemia, arrhythmias, or abnormal heart rate response
- Interpret exercise or pharmacologic findings
- Generate and sign the final stress test report
If your responsibility is to read the test and produce the official interpretation, CPT 93018 is your code.
When Should You Bill CPT 93018?
Use CPT 93018 when:
✔ You interpret the stress test
You did not perform the test itself—your role is medical interpretation.
✔ You review all collected data
Such as:
- ECG tracings
- ST-segment response
- Arrhythmias
- Heart rate recovery
- Blood pressure response
- Symptoms during exercise
- Duration and workload (METs)
✔ You produce the final written report
Not a note, but a true diagnostic interpretation.
✔ You sign the interpretation
Unsigned interpretations are automatically denied.
✔ Another entity performed the test
Meaning the facility or clinic already billed CPT 93017 (and someone billed 93016 for supervision). Ensure cleaner claims for non-Doppler echo studies with our CPT 93307 Echocardiogram Without Doppler Billing Guide updated for 2024–2025 coding and payer requirements.
✔ The stress test was actually performed
93018 cannot be billed if the test was cancelled before ECG data acquisition.
What CPT 93018 Includes
CPT 93018 covers the entire interpretive process, including:
1. Review of the baseline ECG
Assessing rhythm and conduction before stress begins.
2. Analysis of exercise data
Evaluating:
- Heart rate response
- Blood pressure changes
- Functional capacity
- METs achieved
- Exercise duration
3. ST-segment evaluation
Assessing:
- ST depression
- ST elevation
- Morphology changes
- Localization of ischemia
4. Arrhythmia evaluation
Review for:
- PVCs
- PACs
- Atrial fibrillation
- Ventricular tachycardia
- Conduction abnormalities
5. Symptom correlation
Comparing symptoms with ECG or BP changes.
6. Interpretation of pharmacologic response
(Lexiscan, Dobutamine, Adenosine)
7. Diagnostic conclusion
Example conclusions:
- “Normal stress test—no ischemia”
- “Positive for inducible ischemia in inferior leads.”
- “Nondiagnostic due to failure to reach target HR”
- “Abnormal BP response—hypertensive”
8. Recommendations
Examples:
- Further imaging
- Medication adjustment
- Clearance for surgery
- Repeat the stress test at an interval
9. Final signature
Electronic or handwritten.
Documentation Requirements for CPT 93018
Your documentation must be clear, complete, and diagnostic.
Below is what payers expect.
✔ 1. Indication for the stress test
Examples:
- Chest pain (R07.9)
- Shortness of breath (R06.02)
- Abnormal ECG (R94.31)
- Hypertension (I10)
- Atrial fibrillation (I48.91)
- CAD evaluation (I25.10)
✔ 2. Description of the stress method
State:
- Bruce protocol
- Modified Bruce
- Naughton
- Dobutamine
- Lexiscan
✔ 3. Data reviewed
Heart rate, BP, ECG findings, duration, and symptoms.
Avoid common ECG billing errors by reviewing our comprehensive CPT 93000 12-Lead ECG Billing Guide built to support cardiology practices seeking cleaner claims.
✔ 4. Interpretation of ECG changes
Required for compliance:
- ST-segment changes
- Rhythm changes
- Hemodynamic response
✔ 5. Diagnostic conclusion
A 1–2 sentence formal conclusion.
Improve accuracy for 24-hour cardiac monitoring with our CPT 93224 Holter Monitor Billing Guide
including documentation, hooks, interpretation rules, and NCCI edits.
✔ 6. Clinical recommendations
Not mandatory, but improves clarity.
✔ 7. Signed interpretation
No signature = denial.
Prior Authorization Requirements for CPT 93018
Authorization requirements apply to the stress test as a whole, not the individual codes.
Therefore:
👉 If the stress test requires authorization, CPT 93018 also requires authorization.
Here is how payers handle it:
Medicare
- Does NOT require prior authorization
- Interpretation must be medically necessary
- The stress test must have been validly performed
Medicaid
State-specific:
- Some require PA for all stress tests
- Some require PA only for pharmacologic stress
- Some do NOT require PA at all
Commercial Insurance
Most commercial plans DO require authorization for stress tests.
| Payer | Authorization Needed? |
| Aetna | Yes |
| UHC | Yes |
| Cigna | Yes |
| Anthem/BCBS | Often yes |
| Humana | Yes |
| Ambetter | Yes |
If the PA is missing, the interpretation (93018) is denied even if the other components were approved.
Common Denials for CPT 93018
Here are the most frequent denial reasons—and how to avoid them:
❌ 1. Missing signature
Always sign the final report.
❌ 2. No diagnostic conclusion
Reports must include an actual interpretation, not just “reviewed.”
❌ 3. Missing or unclear ECG analysis
You must document:
- ST-segment behavior
- Rhythm changes
- Symptoms
- BP/HR response
❌ 4. No prior authorization
If the payer needs PA, all stress test codes are denied.
❌ 5. Incorrect pairings
Example:
Billing 93018 when the test was never performed (93017).
❌ 6. Submitting the interpretation before the test documentation is completed
The report must reflect the actual data.
❌ 7. Duplicate claims
Only one interpreting provider may bill 93018.
❌ 8. Billing 93018 for a “preliminary note.”
Only the final report qualifies.
Correct Billing Scenarios
Scenario 1 — Cardiologist Interprets Hospital-Performed Test
The hospital performs a stress test
Hospital bills 93017
Cardiologist interprets
Billing:
- Cardiologist → 93018
Scenario 2 — Independent Cardiologist Interprets Outside Test
Primary care office conducts stress test
PCP bills 93017
Cardiologist reviews tracings and writes the final report
Billing:
- Cardiologist → 93018
Scenario 3 — Clinic Performs Test, Outside Cardiologist Reads It
The clinic conducts the test
Clinic bills 93017
External cardiologist receives tracings and interprets
Billing:
- Cardiologist → 93018
Final Thoughts
CPT 93018 is a critical billing code for physicians who interpret cardiovascular stress tests. Accurate interpretation, thorough documentation, and compliance with payer requirements are essential to ensure proper reimbursement. Many denials occur simply because the interpretation lacks sufficient detail or the stress test lacked prior authorization. Strengthen remote monitoring workflows using our CPT 93228 Mobile Cardiac Telemetry Billing Guide covering setup, technician involvement, interpretation, and billing requirements.
If your practice needs help managing stress test billing, improving cardiology workflows, or minimizing denials, Global Tech Billing LLC offers specialized cardiology billing expertise to support your team.
Frequently Asked Questions (FAQ)
1. Can NPs or PAs bill CPT 93018?
Usually, no interpretation is a physician-level service unless payer policies explicitly allow otherwise.
2. Is 93018 used for stress echo?
No. Stress echo uses different codes:
- 93350
- 93351
3. Can 93018 be billed without 93016 or 93017?
Only if someone else billed those codes.
93018 cannot stand alone if no stress test occurs.
4. Does 93018 require prior authorization?
Only when the stress test itself requires authorization.
5. Can two cardiologists bill 93018 for the same test?
No—only one provider can bill per test.
6. Can 93018 be billed with an E/M visit?
Yes, if the visit is significant and separate.
Use modifier 25.
7. Is telehealth interpretation allowed?
Yes. Interpretation can be remote — unlike supervision.
