# Stress Echo Codes



## geigert

Hello,
I have been a certified coder for 6 years now but am starting new in the Cardiology Specialty and am having a little trouble with how to code Stress Echos.  We send out some of our procedures to a contract coder and I am not sure I agree with how these are being coded.  Here is a sample documentation.

Stress Echo:
Left Ventricle
The left ventricular chamber size is normal.  Mild concentric left bentricular hypertrophy is observed.  There is normal left ventricular systolic function. Ejection fraction estimated at 55-60%.  Normal left ventricular diastolic filling is observed.

Left Atrium
The left atrium is mildly dilated.

Right Ventricle
The right bentricular cavity size is normal.  The right ventricular global systolic function is normal.

Right Atrium
The right atrial cavity size is normal.

Aortic Valve
There is no dilation of the aortic root.  There is no aortic valve stenosis.  There is no aortic regurgitation.  There is a trace amount of aortic valve regurgitation.

Mitral Valve
The mitral valve leaflets are mildly thickened.  There is no mitral valve stenosis.   There is mild mitral valve regurgitation observed.

Triscupid Valve
The tricuspid valve leaflets are mildly thickened.  There is trace tricuspid valve regurgitation present.

Pulmonic Valve
There is no pulmonic valve stenosis present.  There is no pulmonic regurgitation.

Pericardium
There is no pericardial effusion.

Aorta
There is no dilatation of the ascending aorta.

Pulmonary Artery
Unable to detect peak tricuspid regurgitant velocity for pulmonary artery systolic pressure calculation.

Venous
The venous system is not well visulalized.

Technical Comments
The technical quality of this study is adequte.  This echocardiogram was performed using 2D, m-mode, color and spectral Doppler.

Stress
Patient EKG is normal.  but there is 1mm J-point elevation throughout at rest.  Patient exercised for 12 minutes and 45 seconds, achieving a peak heart rate of 161bpm, which is 92% MPHR.  He also achieved a double product of 26,000.  At peak stress there is 1mm Upsloping ST depression at peak which resolved by one minute in recovery.  Impression: Negative Stress ECG.

Conclusion:
Impression: Negitive Stress ECG.
Impression: Negative Echocardiographic Stress Test.
Patient's resting EKG shows 1mm J-point elevation throughout at rest (Renomalization abnormalities).  Patient exercised for 12 and 45 seconds, achieving a peak heart rate of 161bpm, which is 92% MPHR.  He also achieved a double product of 26,000.  At peak stress there is 1mm Upsloping ST depression at peak which resolved by one minute in recovery.  
Echocardiographic images obtained at rest and exercise show generalized improved regional wall motion throughout as well as a decrease in size of the LV chamber dimension.

We bill only the professional component as we do this test in the Outpatient department of our hospital.
I think this should be coded as follows:
93350-26 / 93320-26 / 93325-26 /93016 / 93018
The Contract Coder says it should be billed as:
93350-26 / 93016 / 93018 / 93306-26/59

I do not agree with billing the 93306 with the Stress Echo 93350 because I found the following statement on the Medicare Website: "It is medically inappropriate, and contradicts CPT descriptors, to submit CPT 93306, 93307 or 93308, preformed in conjunction with CPT 93350, as 93350 includes a 93306, 93307 or 93308 service."
( http://www.cms.gov/medicare-coverage-database/lcd_attachments/28565_28/l28565_cv026_cbg_10012010.pdf ) 

Does anyone know of any other resources that would state you could bill the 93306? or is there an experienced cardiology coder out there who can explain to me why this would be correct or incorrect?

Any imput is greatly appreciated.  Thanks much


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## Jess1125

geigert said:


> Hello,
> I have been a certified coder for 6 years now but am starting new in the Cardiology Specialty and am having a little trouble with how to code Stress Echos.  We send out some of our procedures to a contract coder and I am not sure I agree with how these are being coded.  Here is a sample documentation.
> 
> Stress Echo:
> Left Ventricle
> The left ventricular chamber size is normal.  Mild concentric left bentricular hypertrophy is observed.  There is normal left ventricular systolic function. Ejection fraction estimated at 55-60%.  Normal left ventricular diastolic filling is observed.
> 
> Left Atrium
> The left atrium is mildly dilated.
> 
> Right Ventricle
> The right bentricular cavity size is normal.  The right ventricular global systolic function is normal.
> 
> Right Atrium
> The right atrial cavity size is normal.
> 
> Aortic Valve
> There is no dilation of the aortic root.  There is no aortic valve stenosis.  There is no aortic regurgitation.  There is a trace amount of aortic valve regurgitation.
> 
> Mitral Valve
> The mitral valve leaflets are mildly thickened.  There is no mitral valve stenosis.   There is mild mitral valve regurgitation observed.
> 
> Triscupid Valve
> The tricuspid valve leaflets are mildly thickened.  There is trace tricuspid valve regurgitation present.
> 
> Pulmonic Valve
> There is no pulmonic valve stenosis present.  There is no pulmonic regurgitation.
> 
> Pericardium
> There is no pericardial effusion.
> 
> Aorta
> There is no dilatation of the ascending aorta.
> 
> Pulmonary Artery
> Unable to detect peak tricuspid regurgitant velocity for pulmonary artery systolic pressure calculation.
> 
> Venous
> The venous system is not well visulalized.
> 
> Technical Comments
> The technical quality of this study is adequte.  This echocardiogram was performed using 2D, m-mode, color and spectral Doppler.
> 
> Stress
> Patient EKG is normal.  but there is 1mm J-point elevation throughout at rest.  Patient exercised for 12 minutes and 45 seconds, achieving a peak heart rate of 161bpm, which is 92% MPHR.  He also achieved a double product of 26,000.  At peak stress there is 1mm Upsloping ST depression at peak which resolved by one minute in recovery.  Impression: Negative Stress ECG.
> 
> Conclusion:
> Impression: Negitive Stress ECG.
> Impression: Negative Echocardiographic Stress Test.
> Patient's resting EKG shows 1mm J-point elevation throughout at rest (Renomalization abnormalities).  Patient exercised for 12 and 45 seconds, achieving a peak heart rate of 161bpm, which is 92% MPHR.  He also achieved a double product of 26,000.  At peak stress there is 1mm Upsloping ST depression at peak which resolved by one minute in recovery.
> Echocardiographic images obtained at rest and exercise show generalized improved regional wall motion throughout as well as a decrease in size of the LV chamber dimension.
> 
> We bill only the professional component as we do this test in the Outpatient department of our hospital.
> I think this should be coded as follows:
> 93350-26 / 93320-26 / 93325-26 /93016 / 93018
> The Contract Coder says it should be billed as:
> 93350-26 / 93016 / 93018 / 93306-26/59
> 
> I do not agree with billing the 93306 with the Stress Echo 93350 because I found the following statement on the Medicare Website: "It is medically inappropriate, and contradicts CPT descriptors, to submit CPT 93306, 93307 or 93308, preformed in conjunction with CPT 93350, as 93350 includes a 93306, 93307 or 93308 service."
> ( http://www.cms.gov/medicare-coverage-database/lcd_attachments/28565_28/l28565_cv026_cbg_10012010.pdf )
> 
> Does anyone know of any other resources that would state you could bill the 93306? or is there an experienced cardiology coder out there who can explain to me why this would be correct or incorrect?
> 
> Any imput is greatly appreciated.  Thanks much



I agree with the way you would code this for the reason above from Medicare policy. I would code it 93350.26, 93016, and 93018. If the doppler/color flow is documented as it is above, then I would bill those out in addition to 93350.26. 

Jessica CPC, CCC


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## geigert

Thanks  for such a quick reply Jessica!

Do you know of any other reference that would address this situation that I could use to convience my Doctor's that we cannot bill the 93306 in addition to the 93550?


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## Jess1125

geigert said:


> Thanks  for such a quick reply Jessica!
> 
> Do you know of any other reference that would address this situation that I could use to convience my Doctor's that we cannot bill the 93306 in addition to the 93550?



I would look at the CPT code 93350 specifically:
Echocardiography, transthoracic, real-time with image documentation (2D), includes M-Mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report;

The 2D and M-mode if performed are already included in the code. 

CCI edits also bundle the 93306 with 93350. Sorry I don't have anything better!

Jessica CPC, CCC


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## peeya

I have a question here. If the test is done at an outpatient hospital setting & the Doctor is billing for the professional part of it ony then how come it is not billed as 93351-26, 93320-26 & 93320-26 ?


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## geigert

The reason you can't use the 93351 in the Outpatient hospital setting is because that code includes the 93015. If you go look at the 93015-93018 range the 93016-93018 are three components of the 93015 broken out. As physicians we can only bill the 93016 & 93018 components while the 93017 is the technical component that we can't bill in Outpatients since we don't own the equipment.


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## Lisa Bledsoe

*93351*

You can code 93351, but then you can't code any code from 93015-93018.  If there was continuous ecg monitoring with physician supervision (93351) that encompasses all components of 93015-93018.  *However, please correct me if I am wrong!*  I too have been certified for many years, and just inherited Cardiology!


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## geigert

You are correct that the 93351 can be used if you perform all parts of the codes 93015-93018.  Since in the Outpatient department you do not own the equipment you do not perform services of 93017 and therefore cannot bill the 93551.


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## peeya

But can we not bill 93351 with modifier 26? Because the modifier implies that the physician did only the Professional component part of the service.


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## Jess1125

peeya said:


> But can we not bill 93351 with modifier 26? Because the modifier implies that the physician did only the Professional component part of the service.



You ARE able to bill 93351 with a -26 modifier. The code has a PC/TC indicator of "1" on the Medicare physician fee schedule meaning you can use the -26/TC modifiers. 

I get where you're coming from and the logic but it's okay. 

Jessica CPC, CCC


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## peeya

So we can bill 93351-26 in the outpatient/inpatient hospital setting. Thanks


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## Jess1125

peeya said:


> So we can bill 93351-26 in the outpatient/inpatient hospital setting. Thanks



Yes, I do it all the time for some of the outpatient ones.  (Don't ask, it's a complicated situation!)

Jessica CPC, CCC


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## cardiorookie

*E&M with modifier 25 and stress echo in the office*

Good evening to all, I am also a rookie biller by necessity, 2 commerical carriers have denied the EKG  and not sure if the 59 should be used with the stress echo. I have to appeal the claim, has any one seen denials ?


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## OliviaPrice

cardiorookie said:


> Good evening to all, I am also a rookie biller by necessity, 2 commerical carriers have denied the EKG  and not sure if the 59 should be used with the stress echo. I have to appeal the claim, has any one seen denials ?



I just want to clarify....when you say EKG do you mean the 93000, 93005, 93010 codes or do you mean the 93015, 93017, 93016, 93018 codes?  I know it may sound like a silly question to some, but I've had people call the stress test portion an EKG so I thought I would check.


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## jbhansen

Per CMS Transmittal 1810 it was clarified "that CPT code 93351 (26) is payable when performed by a physician in a facility setting".  I would assume since the code includes both the echo and stress test portions that when billing with the 26 modifier that is saying only the professional portions of the stress test (represented by 93016 & 93018) were done by the physician.  Per the ASE (American Society of Echocardiography) FAQs in their December 2009 Coding and Reimbursement Newsletter, the difference between 93350 and 93351 is that "93351 combines the stress test with a stress echo.  It is reported when one physician does both the stress test and stress echo.  93350 is a stress echo code that doesn't include the stres test.  When one physician performs the echo portion, and another physician performs the stress test, each physician reports his service as applicable with codes 93350 and the relevant stress test codes (93015-93018)."  And also states "Code 93351 is intended for use when the physician performs the services of both the stress echo and the stress test in any setting.  CMS has clarified that code 93351 is payable when provided by a physician in a facility setting.  Modifier 26 should be added to designated the physician service." (A bit of history...when the code 93351 was first added to CPT in January 2009 it did NOT have a PC/TC split and instruction at that time was to only use it in an office setting where the physician owns the equipment and employs the technician.  CMS's Transmittal 1810 in September 2009 changed this, back-dating the effective date to January 1, 2009.)

My question is whether 93351-26 should be used if only the interp/report portion (93018) of the stress test was done by the physician (in addition to the stress echo), if the physician interpreting and reporting did not personally supervise the stress test or if 93350-26 and 93018 should be used instead?


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