Anesthesia Coding Alert

"Billing for transesophageal echocardiography (TEE) is one of the gray areas of anesthesia reimbursement. Many Medicare carriers have local reimbursement policies regarding the procedure, but most do not specifically state how it relates to anesthesia. TEEs require special training and certification, so the correct code depends on who performs which part of the procedure. It also is important to know your local regulations before seeking TEE reimbursement.

What Is TEE?

TEE is an invasive procedure that involves placing a transducer on the tip of an endoscope. The scope is inserted into the patients esophagus to record a two-dimensional echocardiograph. Its considered standard care during certain procedures on adults or children. These can include the diagnosis of myocardial ischemia (414.8), confirmation that valve reconstruction and other surgical repairs are successful, or to provide diagnostic information that could not be gotten preoperatively by a less invasive method. One advantage that TEE has over other monitoring procedures such as transthoracic echocardiography (TTE) is that it may be left in place and used throughout a surgical procedure to detect problems and continually monitor key parameters instead of being used intermittently.

A half-dozen codes in CPT Codes 2000 apply to TEE. The two primary codes are CPT 93312 (echocardiography, transesophageal, real time with image documentation [2D] [with or without M-mode recording]; including probe placement, image acquisition, interpretation and report) and 93315 (transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report). Related codes for the procedure are 93313 (echocardiography, transesophageal, real time with image documentation [2D] [with or without M-mode recording]; placement of transesophageal probe only), 93314 (echocardiography, transesophageal, real time with image documentation [2D] [with or without M-mode recording]; image acquisition, interpretation and report only), 93316 (transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only) and 93317 (transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and report only).

Correct Code Depends on Training

This procedure requires special training and certification, so most facilities have a technician on staff to perform diagnostic TEEs. Cindie Capito, physician anesthesia coder for the practice group Southern Tier Anesthesiologists PC, in Olean, N.Y., offers these examples of how the procedure should be coded, depending on who performs it and what level of service is provided.

1. An anesthesiologist places the probe, and a cardiologist interprets the report: The anesthesiologist bills with 93313-26 (placement of transesophageal probe only; professional component), and the cardiac surgeon bills 93314-26 (image acquisition, interpretation and report only; professional component). This is how many TEEs are performed, provided the hospital or other place of service owns the equipment.

2. An anesthesiologist who has been trained and certified in TEE inserts the probe and performs the entire procedure on equipment he or she owns. In this case, he or she bills with 93312. But it is important to note that this code has both technical and professional components. The anesthesiologist must own the equipment before billing for the technical component (see below). The procedure must be performed for diagnostic purposes rather than monitoring purposes before the anesthesiologist can bill using this code.

3. An anesthesiologist who has been trained and certified in TEE inserts the probe and interprets and furnishes the reports, but does not own the equipment. He or she bills with 93312-26. This indicates that the anesthesiologist performed the entire procedure but cannot bill for the technical component because he or she does not own the equipment.

The same types of scenarios would apply to using codes 93315, 93316 or 93317. The key factor to consider when using these codes instead of 93312 or 93313 is the patients underlying condition; these codes are used when the patient has congenital cardiac anomalies. The anesthesia provider could use code 01922 (anesthesia for non-invasive imaging or radiation therapy) when the procedure is performed on a patient with congenital heart problems.

Reimbursement for 93312-26 is significantly higher than 93313-26, as would be expected for a procedure with a higher level of involvement. Some anesthesiologists may be tempted to code with 93312-26 because of that, but Judy Martin, joint billing administrator for Anesthesia Services of Lynchburg Inc., a medical billing company in Virginia, warns that you cannot bill this code when you are the technician performing the entire procedure if you are not responsible for all components of the procedure as well as interpreting and furnishing a report. Obviously, the biggest problem with this is that its fraud, she says. If an anesthesia provider plans to code for TEEs using 93312, there had better be documentation of his or her training.

What Do Carriers Want?

As with virtually all medical procedures, guidelines for coding and reimbursement can vary from carrier to carrier and from one state to the next. Most Medicare carriers have local policies that outline the procedure and when it is most likely to be performed. A list of appropriate ICD-9 codes supporting medical necessity is also common (such as codes 394.0-394.9 for diseases of the mitral valve or 402.0-402.91 for hypertensive heart disease). Most do not specify how the anesthesia professional fits into the picture or any stipulations on who can perform the procedure.

At one end of the spectrum are some commercial carriers. For example, Blue Cross/Blue Shield of Tennessee prohibits an anesthesiologist or certified registered nursing assistant (CRNA) from performing TEEs. The policy says, When TEE is used for monitoring during cardiac surgical procedures, the placement of the probe is covered (code 93313/93316), but the evaluation is not allowed to the anesthesiologist/CRNA, as this is a monitoring service.

Meanwhile, Xact Medicare in Pennsylvania is at the opposite end of the spectrum. Its manual lists TEE as a reasonable and medically necessary service that may be provided in addition to the anesthesia services.

Even when the state will allow anesthesiologists to bill for TEE, some may not follow through with it. For example, Medi-Cal, a California Medicare carrier, requires that a written report accompany the TEE procedures documentation. The report must be dictated and placed in the patients chart. Some anesthesiologists do not want to dictate separate reports, so they simply do not bill the TEE when it is done during a surgical procedure. If TEE is done separately, such as for a congenital heart patient, the anesthesia provider bills for the anesthesia. The cardiologist performing the TEE is responsible for the report.

Martin says that part of the frustration when billing for TEE is that some carriers may not reimburse for it even if the documentation is there. We never found any set guidelines for Medicare, so we would file using the procedure code and modifiers according to what information we had. We sent it in with the anesthesia record and operative report, but it was always denied, she says. We dont even bother filing for it now because every claim came back. Its very frustrating, especially when the anesthesia professional has gone through special training to be certified to do it.

The Bottom Line

The bottom line when coding for TEE is that the anesthesia provider needs to be familiar with local regulations to know whether he or she can bill for TEE in the first place. If it is permitted, the person performing the procedure must have the documentation to prove TEE training and certification. Any anesthesiologist who is involved with the procedure but does not perform everything personally must distinguish between the codes and use the correct one for his or her situation."