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Anesthesia Coding Alert

Certification May Be Critical to TEE Reimbursement

Published on Wed May 01, 2002

Transesophageal echocardiography (TEE) is a diagnostic procedure and monitoring tool that anesthesiologists are often asked to assist with or perform. Many local Medicare carriers, however, are unclear regarding whether or how anesthesiologists are to be reimbursed for their involvement in the procedure. Before coding for TEE, you should ensure that the anesthesia provider's TEE training (if the carrier requires it) and the role that he or she played during the procedure are documented so the correct codes can be used.

Coding Options for TEE

The TEE codes (93312-93318) are differentiated by whether the procedure is performed on a patient with congenital cardiac anomalies and by what portion of the procedure the physician handled. Codes 93312 (Echocar-diography, transesophageal, real time with image documentation [2D] [with or without M-mode recording]; including probe placement, image acquisition, interpretation and report) and CPT 93313 ( placement of transesophageal probe only) are commonly used to report TEE procedures, with many anesthesiologists only billing 93313 for probe placement. Even so, coders such as Cindy Clark, coding supervisor with the physician group Anesthesiology Consultants in Savannah, Ga., say that getting reimbursed is not always easy.

"We have one physician in our group who has the training for placing the TEE probe," she says, "so we only bill 93313 for the TEE placement. We attach a copy of the anesthetic record that indicates the TEE probe was placed and which doctor placed it, but we still have difficulty getting the code paid."

Code 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) is appropriate for monitoring purposes when the physician is providing anesthesia during cardiac surgery, says Carla Thibodeaux, CPC, anesthesia coder with Tejas Anesthesia in San Antonio. It is often reported with modifier -26 (Professional component) because the physician does not usually own the equipment. However, because the code is relatively new, Thibodeaux points out that there may be stipulations attached such as whether the anesthesiologist needs special training certifications or whether there needs to be a formal report in the patient's medical record to bill for and receive reimbursement. Some carriers' policies also state that this monitoring code is not a covered service intraoperatively.

Coding Depends on Training

The entire TEE procedure includes several different activities placing the probe, acquiring the test image, interpreting the test results and reporting the results. Many anesthesiologists, such as the physician in Clark's group, are only trained to perform probe placement. But if your physicians are trained and certified to perform other aspects of the procedure, coding can be handled several ways, depending on the anesthesiologist's involvement in a particular case:

  • The anesthesiologist places the probe, and the cardiologist interprets the report. The anesthesiologist bills with 93313-26. The cardiologist bills with 93314-26 ( image acquisition, interpretation and report only; professional component). This is how most TEEs are coded, assuming that the hospital or place of service owns the equipment used.
  • An anesthesiologist who has been trained in TEE places the probe and performs the entire procedure. If he owns the equipment, he codes with 93312. If he does not own the equipment, he bills 93312-26 to indicate that he was responsible for the professional component of the procedure but not the technical component. The procedure must be performed for diagnostic not monitoring purposes before the anesthesiologist can bill using this code.

    Note: The same physician can also provide anesthesia during the procedure instead of having a second anesthesiologist present. But an additional fee for anesthesia is not charged because the original physician is already charging for the procedure, lines and TEE probe placement. Having another doctor code 01922 (Anesthesia for non-invasive imaging or radiation therapy) would be considered overbilling in this situation.

    The same general guidelines apply to using the other TEE codes (93315, 93316 and 93317). The primary consideration when using 93315-93317 is the patient's underlying condition. These three codes are used when the patient has congenital cardiac anomalies such as an unspecified defect of the septal closure (745.9) or congenital mitral insufficiency (746.6).

    Clark adds that some practices have luck getting paid for TEE when appending modifier -59 (Distinct procedural service) to the procedure code but that caution should be used when billing this way. Modifier -59 is generally used to designate second procedures performed on the same day (such as separating line placements from TEE) and not when placing the probe for TEE. However, some recent local medical review policies such as one developed earlier this year by Wisconsin and several other states now ask that anesthesiologists use modifier -59 when billing intraoperative TEE because it is a separate and distinct procedure.

    Documenting to Get Paid

    As with any procedure, clear and accurate documentation will help physicians get appropriate reimbursement for TEE. Most Medicare carriers have created a list of appropriate ICD-9 codes that support medical necessity for the procedure. Clark says TEEs are used primarily to detect cardiac emboli, heart valve malfunctions, cardiac tumors and heart disease. Some of the ICD-9 diagnoses associated with these conditions that may support medical necessity include the following:

  • 164.1 Malignant neoplasm of heart

     

  • 212.7 Benign neoplasm of respiratory and intrathoracic organs; heart

     

  • 276.5 Disorders of fluid, electrolyte, and acid-base balance; volume depletion

     

  • 391.1 Acute rheumatic endocarditis

     

  • 444.1 Arterial embolism and thrombosis; of thoracic aorta.

    Once you have ensured that the patient's diagnosis adheres to the carrier's guidelines for medical necessity, the next factor to clearly document is the physician's training related to TEE, usually by submitting his or her certificate to carriers and including the information on applications for carriers. In addition, "be sure your physicians are documenting whether they are interpreting, reporting or performing the procedure," Clark advises, so the correct code can be used.

    Ask your carrier for its requirements regarding a written report. Some carriers require that a written TEE report accompany the original claim when TEE is performed during noncardiac surgical procedures.

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