Author: Tony Mira
The Anesthesia Insider
Summary: The documentation of transesophageal echocardiography poses a number of interesting questions as there are a number of procedural options. As billing guidelines often change, it is always useful to review the current state of CPT and payer policy.
There was a time, not too long ago, when cardiovascular anesthesiologists relied on three main monitoring devices to manage a patient’s cardiovascular functions during a CABG. The development of transesophageal (TEE) probes to monitor heart function via ultrasound from the esophagus changed that. Many anesthesia providers now find the TEE probe one of the most useful monitors. This diagnostic tool now provides real-time imaging of heart function, especially during critical phases of the procedure.
Coding for TEE is based on the same basic logic as for radiology and ultrasound procedures: there is one code for placement of the probe (93313), one code for interpretation of the images (93314), and one for the comprehensive service (93312). There are also codes for enhanced services: Doppler echocardiography pulsed wave and/or continuous wave with spectral display (93320), follow-up Doppler study (93321), color flow velocity mapping (93325), and 3D rendering with interpretation and reporting of CT, MRI, ultrasound or other tomographic modality (76376).
While TEE is often billed in conjunction with anesthesia and invasive monitoring for cardiovascular cases, it may be performed as a stand-alone diagnostic service. If TEE is being performed by an anesthesiologist or a cardiologist as a separate diagnostic service, it may require a MAC anesthetic, which is also separately billable. Needless to say, each procedure code has its own fee schedule payment. The Medicare fee schedule allowable for 93312 is approximately $115, while payment for just the placement of the probe is $29.
The CPT description of the requirements for 93312 are listed as follows:
* Probe placement
* Image acquisition
When a procedure requires a report, it is never quite clear what is expected. While many providers have developed detailed report formats, these involve preparing a separate document for each case. Since so many practices now use automated anesthesia records, the goal of which is to minimize the need for paper documentation, the question is whether the necessary details can simply be captured in a procedure note or a pre-formatted macro. To this end, the following is a summary of the critical data elements that should be reported:
*Indication of the full service (a statement indicating TEE probe placement, interpretation, image acquisition and report)
* Modalities (e.g., 2D/3D/CFM/PWD/CWD/Contrast)
* Echo and Doppler measurements, including annulus, stenosis, regurgitation, leaflet morphology, leaflet motion (aorta, valves, atria, ventricles pericardium and pleura)
* Complications, if any
* Post-intervention follow-up study details (could be a separate report or included)
To be clear, coders must be able to determine the level of service provided. There was a period of time during which some Medicare intermediaries required TEE certification for the comprehensive service but this is no longer a requirement.
A review of the Transesophageal Echocardiography section of the current ASA Relative Value Guide reveals a few other coding options:
* Codes 93315, 93316 and 93317 should be used as listed above for cases involving congenital cardiac abnormalities.
* Code 93318 is listed as being a coding option for cases where the TEE probe is primarily used for monitoring purposes. While this code is listed in the ASA Relative Value Guide, it is not included in Medicare or Medicaid fee schedules or those of most other commercial payers. For this reason, we require the TEE provider to document the purpose of the TEE service, which should include one of the following designations: “diagnostic” or “for monitoring.” Alternatively, the provision of a TEE report (interpretive study) to the billing office will act to support the diagnostic nature of the TEE service.
* Code 93355 is a more recent addition for TEE when used during a transcatheter cardiac procedure [e.g., TAVR, TMVR (now called TEER by Medicare)]. This code is payable by Medicare, with a national reimbursement rate of $230. To bill this code, TEE providers must meet the minimum threshold of BOTH placing the probe AND performing the interpretive study. Any other modalities, such as the use of Doppler or color flow mapping, will be bundled into 93355. CMS has recently published a decision which allows the billing of 93355 only when it is performed by someone who is not also providing anesthesia on the case. In other words, an anesthesiologist can bill for 93355 as long as someone else, i.e., his/her partner, was providing the anesthesia.