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Anesthesia Coding Alert

Follow Your Step-by-Step Guide to Nailing Down the Correct TEE Code Every Time

Published on Sun Jan 25, 2009

This procedure isn't always a wash when it comes to cardiac anesthesia.

Discover if your transesophageal echocardiography (TEE) anesthesia is payable or included in the procedure using this get-the-right code action plan.

Distinguish Between Diagnostic and Monitoring

The most common problem associated with billing and obtaining reimbursement for TEE is determining whether the procedure is for diagnostic (93312-93317) or monitoring (93318) purposes, says Kelly Dennis, MBA, ACS-AN, CPC, CPC-I, with Perfect Office Solutions of Leesburg, Fla. It is often difficult to tell whether the TEE was diagnostic or not unless your physician identifies the study's purpose.

In order to bill for a diagnostic TEE, a written report is needed. In many cases people will only write a report if it is for diagnostic or therapeutic reasons. If you were just using the TEE for monitoring there would be little reason to report that in writing. If you can't tell the reason for the TEE from the physician's report it is likely that a Medicare auditor couldn't, either. It's important to let the interpreting doctor know that his reports are not clear and unlikely to withstand the scrutiny of an audit.

For Diagnostic, Determine Type, Role

CPT contains two sets of codes for diagnostic TEE. For a study that involves realtime image acquisition and documentation, you'll use a code from 93312-93315. TEE for congenital cardiac anomalies falls under 93315-93317.

For a diagnostic test, pay attention to whether the anesthesiologist places the probe, interprets and reviews the study, or provides both services.

If the physician does all three, you'll use the global code. For real-time global TEE, use 93312 (Echocardiography, transesophageal, real-time with image documentation [2D] [with or without M-mode recording]; including probe placement, image acquisition, interpretation and report). The TEE for congenital cardiac anomalies global code is 93315 (Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report).

When your anesthesiologist places the probe and does not provide a written report, use the placement-only diagnostic TEE codes. These include:

• 93313 -- Echocardiography, transesophageal, realtime with image documentation (2D)(with or without M-mode recording); placement of transesophageal probe only

• 93316 -- Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe only.

Your physician sometimes might interpret the findings while another physician places the probe. Provided your anesthesiologist is the only physician to issue a written report of the diagnostic TEE, you would code for the "image acquisition, interpretation and report" only with 93314 for real-time TEE and 93316 for TEE for congenital cardiac anomalies.

Pinpoint Doppler to Increase Diagnostic Pay

If your physician performs and accurately documents Doppler echocardiography (ECG) with TEE, don't forget to report the waves or mapping with the appropriate addon code. What they do: Spectral Doppler and color flow Doppler provide information regarding intracardiac bloodflow and hemodynamics.

Good news: The TEE codes do not include Doppler echocardiography (+93320, Doppler echocardiography, pulsed wave and/or continuous wave with spectral display [List separately in addition to codes for echocardiographic imaging]; complete; and +93321, ... follow-up or limited study [List separately in addition to codes for echocardiographic imaging]) and color flow studies (+93325, Doppler echocardiography color flow velocity mapping [List separately in addition to codes for echocardiography]). Pay attention to CPT's allowed base codes.

You can report Doppler ECG wave complete (+93320) or follow-up/limited (+93321) or color flow studies (+93325) with only the global or interpretation and report diagnostic TEE codes: 99312, 99314, 99315, or 99317.

Avoid Truncated Diagnosis Codes

Your anesthesiologist should be as specific as possible when reporting diagnoses attached to TEE use. Merely linking the TEE code to a payable ICD-9 code is not sufficient. Clinical signs or symptoms must be present and documented.

Example: Following a TEE, your anesthesiologist reports the patient had ischemic heart disease (414).Reporting 414 is insufficient. A fourth digit, or fifth when possible, such as 414.10 (Aneurysm of heart [wall]) is more appropriate, and may be covered by your local coverage determination (LCD) for TEE codes 93312-39914. Currently, most areas have an LCD policy on TEE payment. You should review your state's policies and bill accordingly.

Patient Condition Shows Monitoring Opportunities

Since monitoring is part of the procedure's anesthesia,93318 (Echocardiography, transesophageal [TEE] formonitoring 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 not compensated. "Medicare doesn't pay for monitoring, although some commercial insurance companies will," Dennis says.

Keep your eye out, however, for circumstances in which you should consider TEE an additional service, not part of the procedure's usual anesthesia. The American Society of Anesthesiologists (ASA) is clear that the indication for TEE is typically based on a patient's condition rather than a specific surgical procedure, Dennis says. A patient with congenital, functional, or ischemic cardiovascular disease (such as 425.1, Hypertrophic obstructive cardiomyopathy) may require TEE.

What to do: Be sure your anesthesiologist has crystal clear documentation on all TEEs performed, particularly as it pertains to the patient's condition.

Example: TEE has a high level of sensitivity for aortic dissection (441.0, Dissection of aorta). Several other aortic pathologies, including aortic root dilation, aortic ulceration, atherosclerotic plaque, and mural thrombotic material, can be identified with high diagnostic yield by TEE. Use of TEE for such cases may be reimbursable.

Remember: TEE for monitoring is never paid nor is it ever unbundled. When TEE is used in dissection or with valvular repair, your anesthesiologist is diagnosing whether surgery fixed the lesion. Your anesthesiologist is then not monitoring, but telling the surgeon whether his repair has corrected the problem to an acceptable level. Since he is playing an active role in management, he is doing more than just monitoring. Including a full report in this case means you can bill a reimbursable code like 93312 or 93314. If the report labels this as monitoring, you are not entitled to reimbursement.

Watch for Credentials

While there are medical professionals who can interpret TEE images, only TEE certified MDs will be reimbursed for TEE services, says Julee Shiley, CPC, CCS-P, ASC-AN. Only providers with appropriate credentials can bill for the probe placement and recording of images (CPT codes 93306-93351). There may be hospital and/or insurance plan restrictions which limit this service to provision by physicians. Remember TEE for monitoring is considered part of the anesthesia service and is not typically eligible for separate reimbursement --eg.,CPT code 93318 which CCI bundles in addition to anesthesia.

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