Anesthesia Coding Alert

Beware: Most payers won't reimburse for monitoring with CPT 93318 .

Transesophageal echocardiography (TEE) anesthesia has long given fits to coders who need to choose among the procedure's code range (93312-93318). If you're fuzzy on which TEE code will bring in deserved reimbursement, take these tips from the experts.

Determine Role of Line Placement

For a study that involves real-time image acquisition and documentation, you'll use a code from 93312-93314 (Echocardiography, transesophageal, real-time with image documentation [2D] [with or without M-mode recording]...). If your anesthesiologist provides anesthesia for TEE, including probe placement, then performs the exam and also dictates the report, you'll use the global code 93312 (Echocardiography, transesophageal, real-time with image documentation [2D] [with or without M-mode recording]; including probe placement, image acquisition, interpretation and report), unless the procedure was done for a congenital cardiac abnormality.

The other global code, TEE for congenital cardiac anomalies, is 93315 (Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report).

The anesthesia crosswalk for 93312 and the subsequent TEE codes is 01922 (Anesthesia for non-invasive imaging or radiation therapy). You can only report 01922 if your anesthesiologist provided anesthesia while another provider (the cardiologist) placed the probe and did the exam.

Watch: If the anesthesiologist is doing the exam he should not use anesthesia codes, but rather 93312-93318. For a diagnostic test, you'll want to find whether the anesthesiologist placed the probe, interpreted and reviewed the study, or provided both services.

Example: A cardiologist needs to know whether a patient has chronic myocardial ischemia (414.8, Other specified forms of chronic ischemic heart disease) or cardiac valve disorder (395.x, diseases of aortic valve). The anesthesiologist can utilize TEE for diagnostic purposes in this case. You can bill for 93312, "as long as the anesthesiologist performs the placement, image acquisition, and interpretation (including a written report)," says Judy A. Wilson, CPC, CPC-H, CPC-P, CPC-I, CANPC, CMBSI, CMRS, business administrator with Anesthesia Specialists in Virginia Beach, Va.

Pointer: One common roadblock with billing for TEE is determining whether the procedure is for diagnostic (93312- 93317) or monitoring purposes (93318, Echocardiography, transesophageal [TEE] for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing [continuous] assessment of [dynamically changing] cardiac pumping function and to therapeutic measures on an immediate time basis). In order to bill for a diagnostic TEE, you'll need a written report. In fact, you will likely only see a written report if the procedure wasdone for diagnostic or therapeutic reasons. "When in doubt, query the provider," recommends Julie Drueppel, CPC, a billing coordinator in Lincoln, Neb.

Don't Expect Medicare to Pay for 93318

Since monitoring is part of anesthesia, you won't be compensated for 93318. "When a TEE is performed by an anesthesiologist for monitoring purposes only, you may not bill separately for the TEE," Wilson says.

Reasoning: If you check the notes from the encounter, you might find the words "continuous assessment," as you would find in the description for 93318. In this case the anesthesiologist's service is considered additional monitoring, which payers do not consider medically necessary. You're also not likely to find a written report -- a sign that your anesthesiologist was only monitoring the procedure.

In addition, 93318 "is bundled into every anesthesia code with a qualifier of '0' (no modifier allowed) but most commercial payers have adopted the ASA stance and do allow payment for this service when billed with anesthesia," Drueppel says.

Bottom line: "I would encourage all to check their commercial payers' anesthesia policies," Drueppel recommends.

Remember 2 Crucial Modifiers

Ensure your coding tells the right story of what happened during the procedure by attaching the right modifiers. If you append the correct modifiers, there is no reason the services will not be paid, Wilson says.

For many TEE procedures done in a hospital, you'll need to append modifier 26 (Professional component). "The facility that owns the equipment would receive the technical component," says Kelly Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, president of Perfect Office Solutions, In Leesburg, Fla.

Exception: "93313 and 93316 are, by definition, for 'placement of transesophageal probe only' and, therefore, the 26 modifier is not applicable as the code definition itself is a professional service only," Drueppel says.

Some payers may also request that you use modifier 59 (Distinct procedural service) to indicate that TEE is separate from the anesthesia service provided, Dennis says.

Here's why: TEE is most often done during cardiac surgery. Therefore if your anesthesiologist uses TEE during a mitral valve replacement, the 93312 or 93313 should have a 59 modifier to indicate the TEE is separate from the cardiac anesthesia.