Anesthesia Coding Alert

Extra Service Advantage:

Report Doppler Separate From TEE Placement

Published on Sun Aug 21, 2005

Don't miss extra reimbursement if you meet criteria

Focusing your energy on coding TEE probe placements - and ignoring those small additional services such as Doppler flow studies - is a quick way to topple your TEE payments.

Some anesthesia coders might never see cases involving TEE and Doppler, but others might. This can be especially true for coders who deal with a lot of cardiac anesthesia cases.

Physicians often use an echocardiogram to create a picture of the patient's cardiac structures; it shows basic anatomy such as heart muscle and valve leaflets. But when the physician needs more detailed information about the patient's heart, he may rely on a Doppler exam (sometimes called a Doppler flow study) and other monitoring techniques instead for more valuable information.

Don't Report Doppler Solo

When the anesthesiologist opts to use Doppler in conjunction with TEE, CPT lists several codes that could apply to the study. These include:

+CPT 93320 - Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete

+CPT 93321 - ... follow-up or limited study (List separately in addition to codes for echocardiographic imaging)

+CPT 93325 - Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography).

Pair it with echo: The anesthesiologist must use Doppler in conjunction with echocardiography, so you'll also report the appropriate echocardiography code. (You know this because the descriptors instruct you to report 93320-93325 in addition to the echocardiography codes). CPT includes several echocardiography codes (93303-93350), but the ones most commonly used to report the base service are:

CPT 93307 - Echocardiography, transthoracic, real-time with image documentation (2D) with or without M-mode recording; complete

CPT 93308 - ... follow-up or limited study

+CPT 93325 - Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography).

"In cardiac cases, virtually only color Doppler is used to indicate the flow and direction," Scott Groudine, MD, an Albany, NY anesthesiologist, says. "Where the blood is flowing and in what direction is very important in heart valve replacement operations. Spectral Doppler (black and white) is rarely used in the OR for these cases."

Caution: Although you code the procedure, you probably won't report the contrast agent. In most instances, the hospital bills for the contrast material.

Whittle TEE Codes Down to 4 Probabilities

Because the Doppler study is separate from the TEE probe placement, you can bill for both procedures. CPT includes a range of codes related to TEE, but the ones anesthesiologists use most often are:

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 are qualified to perform the entire TEE procedure, interpretation and report. If you're reporting the complete service with 93312, you should append modifier 59 (Distinct procedural service) and include a separate diagnosis for Medicare. Groudine says many of these diagnoses relate to valvular surgery, such as 394.0 (Mitral stenosis), 395.0 (Rheumatic aortic stenosis), 396.0 (Mitral valve stenosis and aortic valve stenosis) and 397.0 (Diseases of tricuspid valve).

93313 - Echocardiography, transesophageal, real time with image documentation (2D) (with or without M-mode recording) placement of transesophageal probe only. This code does not include the interpretation and report; anesthesiologists report 93313 when they place the probe and a cardiologist performs the interpretation and report.

93315 - Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report. Anesthesiologists might also be able to report this if they are credentialed to perform the entire procedure. Physicians who concentrate on cardiac anesthesia are more likely to fall in this category, says Judy Wilson, CPC, CMC, CCP, CRS, business administrator for Anesthesia Specialists in Virginia Beach, Va.

93318 - Echocardiography, transesophageal (TEE) for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing (continuous) ssment of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis. Many anesthesiologists report this code most often because they primarily use TEE probes for monitoring. However, Groudine says 93318 is virtually never paid because monitoring is included in the global anesthesia fee. You can report 93318 for accuracy's sake, but don't expect it to add much to your bottom line.

Don't forget: If the anesthesiologist performs the entire TEE procedure, know who owns the equipment. If your physician does not own the equipment, designate this by appending modifier 26 (Professional component).

Support Services With Reports and Documentation

Before you can charge for both Doppler and TEE services, the physician must complete a formal written report with interpretation. This report should be filed with copies of the image documentation (video or paper, depending on the equipment) so they're available for review by other practitioners or the carrier.

Some coders recommend having a separate billing sheet for TEE to make documentation easier; Wilson says this has been very successful with her group. You can tailor it to meet your group's needs, but information on her sheet includes:

The reason TEE was needed

Any supporting diagnoses (such as the valvular codes listed above)

The surgeon

Who performed the echocardiogram

Appropriate TEE code choices

Whether the anesthesiologist used standard or color Doppler in conjunction with TEE

Check-boxes for modifiers that might apply to the case, such as modifier 26 or modifier 59. Note: Always report modifier 26 if the hospital owns the equipment used during the procedure.

"When the physician uses TEE (with or without Doppler) it is important that the billing office know about it so they can bill appropriately," Groudine notes. "A check-off on the billing sheet is adequate if the anesthesiologists know what they are checking off. If not, a more detailed sheet may be necessary."

Bottom line: Correct coding and appropriate reimbursement for Doppler with TEE services comes back to the same issue as all other cases: documentation. Whatever services you're reporting related to TEE and Doppler, Wilson reminds you to make sure all the requirements are met and that all documentation to support the billing is recorded.