Anesthesia Coding Alert

Hint: Specific diagnoses and extra services can make a difference 

Anesthesiologists often use transesophageal echocardiography (TEE) during cardiovascular cases, but they don't always understand which parts of the service carriers reimburse -- or what documentation you need to correctly code the case. If your physicians fall into these categories, use these expert tips to get their documentation -- and your coding -- back on track.

Know Which Codes Apply to Your Physicians    

CPT includes several codes for TEE, but some usually apply to cardiologists rather than anesthesiologists. The complete group of TEE codes includes:

• 93312 -- Echocardiography, transesophageal, real time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report. Some anesthesiologists have credentials to perform the entire TEE procedure, interpretation and report.

• 93313 -- ... placement of transesophageal probe only. This code does not include the TEE interpretation and report. Submit it when your anesthesiologist places the probe but a cardiologist performs the interpretation and report.

• 93314 -- ... image acquisition, interpretation and report only. This code coincides with 93313: If the anesthesiologist reports 93313, the cardiologist must report 93314.

• 93315 -- Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report. You might be able to report this code if your anesthesiologist is credentialed to perform the entire TEE procedure (especially if he concentrates on cardiac anesthesia).

• 93316 -- ... placement of transesophageal probe only

• 93317 -- ... image acquisition, interpretation and report only. Codes 93316 and 93317 are the same extended descriptors as 93313 and 93314. You'll choose the correct code based on whether the patient has congenital heart problems.

• 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. Many anesthesiologists report this code most often because they use TEE probes for monitoring. Heads up: Most carriers do not pay for 93318 because the global anesthesia fee includes monitoring. You can report 93318 for accuracy's sake, but don't expect it to add much to your bottom line.

Modifier note: Because you can report TEE services in addition to the procedural anesthesia, append modifier 59 (Distinct procedural service) to the TEE code if this is the case. And be sure to include a separate diagnosis for Medicare.

"We also add modifier 26 (Professional component)," says Judy A. Wilson, CPC, CPC-P, CCP, CMC, CMBS, business administrator for Anesthesia Specialists in Virginia Beach, Va. Reporting modifier 26 shows that your physician completed the test but does not own the equipment. Whoever owns the equipment (usually the hospital) bills the same TEE code with modifier (Technical component).

TC Get Specific With Your Diagnoses  

The anesthesiologist decides to use TEE based on the patient's condition rather than the specific procedure. "The patient's disease process and possible diagnostic complications are the determining factors as to which patients will benefit from the use of TEEs," says Lorraine Gledhill, CPC, with Lahey Clinic in Burlington, Mass.

Carriers often prefer detailed diagnoses to support TEE's necessity, such as:

• 086.0 -- Chagas' disease with heart involvement

• 429.3 -- Cardiomegaly

• 429.71 -- Acquired cardiac septal defect

• 394.0 -- Mitral stenosis

• 440.0 -- Atherosclerosis; of aorta

• 427.31 -- Atrial fibrillation

• 996.02 -- Mechanical complication of cardiac device, implant, and graft; due to heart valve prosthesis.

Use your tools: Gledhill's department relies on coding software to help verify which diagnosis codes cross-reference to TEE procedures. "This tool gives us about 160 diagnoses in all," she says.

Still double-check: Even if you have cross-reference software, remember that the program might not have all the answers. For example, some carriers accept V15.1 (Other personal history presenting hazards to health; surgery to heart and great vessels) as a diagnosis supporting TEE. "I do not see V15.1 listed as one of the approved diagnoses [in our program]," Gledhill says. "But that does not necessarily mean it can't be used. Always verify the diagnoses with your carrier."

Encourage Supporting Documentation

With other monitoring techniques available, why would your anesthesiologist choose TEE? Because of the information TEE provides, experts say. TEE provides information regarding surgical interventions, anesthesia effects and the patient's condition that other diagnostic procedures (such as Swan-Ganz catheter placement, 93503, Insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes) do not. 

Another bonus: The anesthesiologist can obtain this information more quickly with TEE than with a Swan-Ganz catheter or other monitoring device.

No matter which TEE code you report, your anesthesiologist needs to thoroughly document the case. Gledhill recommends establishing a process -- with templates -- to help physicians adequately document their work. Good documentation can include:

• dictation of a thorough report covering the physician's examination and findings

• indications for the TEE exam

• atrial, ventricular and aortic assessments with comments

• postprocedure follow-up

• any complications

• the procedure's recording.

"We have a standard process in place," Gledhill says. "The physicians have a dictation template for the TEE documentation, which prompts and guides the provider in his documentation. We also make each physician aware of the proper compliance for submitting TEE codes and stress the possibility of lost revenue if the proper documentation has not been met."

The payoff: When you train your physicians to submit thorough documentation of their TEE services, virtually all of your claims should go through the reimbursement process without red flags. 

"Our anesthesia liaison [in the billing department] tells me that all carriers pay on the first submission attempt, with the exception of Harvard Pilgrim," Gledhill says. "When submitting this service to Harvard Pilgrim, we usually get a denial the first time, but the claim is usually paid on appeal with the supporting documentation from the TEE report.